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UNITED STATES OF AMERICA. 






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TREATMENT 



DISEASES OF THE STOMACH 



AND 



INTESTINES 



BY 1/ 

DR. ALBERT MATHIEU 

PHYSICIAN TO THE PARIS HOSPITALS 




NEW YORK 
WILLIAM WOOD & COMPANY 

1894 



9|£ 



Copyright, 1894, 
By WILLIAM WOOD & COMPANY 



ELECTROTYPED AND PRINTED BY 

THE PUBLISHERS' PRINTING COMPANY 

132-136 WEST 14TH STREET 

NEW YORK 



PREFACE. 



This volume contains a general summary of the thera- 
peutics of diseases of the stomach and intestine. It is im- 
possible to separate the study of the affections of these two 
portions of the digestive apparatus, especially as regards 
general pathology and dyspepsia, and the question of treat- 
ment is hardly more easily divided. The pyloric and ileo- 
csecal valves are anatomical boundary lines much more 
than they are barriers in the domain of normal and morbid 
physiology. 

Two facts brought forward in recent years have changed 
very considerably our views concerning gastro-intestinal 
pathology ; these are the advances made in the chemistry 
of the stomach and the demonstration of the pathogenic 
importance of intoxications of intestinal origin. Our aim 
has been to show clearly in what measure these new ideas 
have modified the indications for treatment, to set forth the 
objects which the therapeutist has to propose to himself, 
and to indicate the means at his disposition for fulfilling 
them. 

We must not forget that the last word is far from hav- 
ing been said ; and if we are better acquainted, though 
still very incompletely, with the processes of gastric diges- 
tion, those of intestinal digestion are yet but imperfectly 
known. However, a gleam of light has now begun to 

iii 



iV PEEFACE. 

penetrate where once reigned the obscurity of pure empiri- 
cism ; and that is something ! 

A few words may be said concerning the division of the 
subject adopted in this book. There is first a chapter on 
semeiological technique, in which we have described the 
principal methods employed for the examination of the 
contents of the stomach, of the f seces, and of the urine, with 
a view especially to the diagnosis of dyspeptic conditions. 
We have limited ourselves to an exposition of the simple 
elementary details which are indispensable to a good clini- 
cal examination. This is not because the physician al- 
ways ought to or can make researches of this kind ; but it 
is by means of them that we have gained what additional 
knowledge we now possess of the nature of dyspepsia, and 
one should be able to carry them out, since they alone give 
us certain information as to the chemical variety of gas- 
tric dyspepsia with which we have to deal. 

In the second part will be found a general study, neces- 
sarily brief, of the diet suitable in case of gastro-intestinal 
dyspepsia. 

The following part, the most important, is a manual of 
general, symptomatic therapeutics. Gastro-intestinal dys- 
pepsia being really but a series of symptomatic complexes, 
its treatment is considered in this place. The reader will 
find arranged in a logical and natural order the clinical 
definition and treatment of the different dyspeptic states 
of the stomach and intestine, viz., hyperchlorhydria, 
atonic nervo-motor dyspepsia, dilatation of the stomach, 
constipation, diarrhoea, and auto-intoxication of gastro- 
intestinal origin. The indications furnished by the great 
dyspeptic complexes are in reality independent of the ex- 
istence of the underlying pathological conditions, although 
the lesions, when they exist, may also themselves present 



PREFACE. V 

special therapeutical indications. There will be found 
therefore in this part of the work directions applicable to 
the treatment of the diseases of the stomach and intestines, 
considered by themselves, and more particularly to the 
treatment of the clinical forms of dyspepsia which are 
named according to the predominance of one or another 
symptomatic element. 

In the last part we treat of the therapeutics of diseases 
of the stomach and intestine. This section is very short 
because the treatment of these diseases is above all symp- 
tomatic and the reader will find that many of the more 
useful indications have been given in the preceding part. 

We have been obliged necessarily to preface the thera- 
peutical portion with some general pathological considera- 
tions, but owing to want of space we have had to make 
this part very brief. We have elsewhere exposed at 
greater length the reasons for our views, somewhat eclec- 
tic it is true, of the nature of the primary and secondary 
dyspeptic states, and to these previous writings we must 
refer the reader. 1 

1 " Traite de Medecine, " vol. iii. Societe Medicale des Hopitaux, 
1891-92. Article on Neurasthenia in the Bibliotheque Charcot- 
Debove. 



CONTENTS. 



FAKT I. 

PAGE 

Diagnostic Technique, 1 

PAET II. 

General Considerations on Diet, . „ . 38 

PAET III. 

Treatment of the Principal Clinical Forms op Dys- 
pepsia AND OF THE MOST COMMON SYMPTOMS OF GASTRO- 
INTESTINAL Diseases, 62 

CHAPTER I. 
Hyperchlorhydria, 66 

CHAPTER II. 

Nervo-Motor Dyspepsia (Atonic or Asthenic Dyspepsia), . 88 

CHAPTER III. 

Dilatation of the Stomach with Permanent Stasis, . . . 128 

CHAPTER IV. 

Treatment of the Painful Phenomena in Diseases of the 
Stomach and Intestine. — Treatment of the Gastric and 
Intestinal Crises, 142 

CHAPTER V. 
Vomiting, 157 

CHAPTER VI. 
Disorders of the Appetite, 159 

CHAPTER VII. 
Constipation, 161 



Viil CONTEXTS. 

CHAPTER VIII. 

PAGE 

Diarrhoea, 192 

CHAPTER IX. 
Gastro-Intestinal Antisepsis, 207 

CHAPTER X. 

Dyspepsia — Acute Indigestion, 221 

CHAPTER XI. 
Gastric and Intestinal Hemorrhage, 226 

PAKT IV. 

Diseases of the Stomach and Intestine, . . .228 

CHAPTER I. 
Gastritis, 229 

CHAPTER II. 

Simple Ulcer and Ulcerative Gastritis, 234 

CHAPTER III. 
Cancer of the Stomach, 243 

CHAPTER IV. 
Enteritis, 248 

CHAPTER V. 
Dysentery, 251 

CHAPTER VI. 
Typhlitis, Perityphlitis, Appendicitis, 254 

CHAPTER VII. 
Intestinal Occlusion, 259 

CHAPTER VIII. 
Cancer of the Intestine, . 265 

CHAPTER IX. 
Intestinal Parasites, 267 

Appendix, 275 



TREATMENT OF THE DISEASES 

OF THE 

STOMACH AND INTESTINE 



PAET I. 

DIAGNOSTIC TECHNIQUE. 



It is very necessary in the beginning of a work of this 
kind to present a summary at once brief and methodical of 
the technique to be followed in the semeiological examina- 
tion of the digestive tube and of its functional action. 
Real progress has been made in this direction of recent 
years, and although what we yet know is but little in 
comparison with what we do not know, and although the 
advances thus far made have to do chiefly with the stom- 
ach, it is nevertheless certain that we have acquired new 
facts of undoubted value bearing upon a study of the 
varieties of dyspepsia and upon the question of its treat- 
ment. At the present day indeed it is impossible to un- 
derstand the nature of, or to diagnosticate, dyspepsia and 
its clinical varieties without a practical knowledge of these 
new methods of examination. 

We cannot here pass in review and criticise in detail 
the different methods of chemical examination of the gas- 
tric juice which have been proposed by various authors, 
and we must content ourselves with reviewing as clearly 
and as briefly as possible those methods which are of the 
most importance, and especially those which may prove 

1 



2 DISEASES OF THE STOMACH AXD INTESTINE. 

the most useful from a clinical point of view. We shall 
dwell especially upon the description of those procedures 
which a personal experience of many years has shown us 
to be really useful. 

This diagnostic study naturally falls under the follow- 
ing heads : 

1. External Examination. 

2. Internal Examination, together with a Chemical 
Study of the Gastric Juice. 

3. Study of the Excreta. 

1. External Examination.— We shall consider very 
briefly the question of external examination, desiring only 
to call special attention to a few important points. 

Simple inspect ion of the abdomen may afford informa- 
tion of a certain value. We can by this means recognize 
the amount, more or less marked, of meteorism and its 
location. Meteorism may be most apparent in the region 
of the stomach or it may involve uniformly the entire ab- 
domen. As is well known, when an obstruction exists in 
the lower part of t ho small intestine, tympanites is present 
in the median portion of the abdomen, which then becomes 
most prominent. Sometimes the exaggerated contractions 
of the stomach or of the intestines may bo observed through 
the thin and distended abdominal walls, and this is a 
symptom upon which Kussmaul has particularly insisted. 
These excessive contractions ma}' be purely nervous or 
they may be a sign of the effort which the digestive tube 
is making to overcome an obstacle, such as a narrowing of 
the calibre of the intestine or a contraction of the pylorus. 

Simple inspection will, again, afford information as re- 
gards the greater or less degree of relaxation of the ab- 
dominal walls. When these are relaxed and flaccid, the 
belly flattens out, as it were, laterally, as the patient lies 
on his back; when he stands up, on the other hand, it falls 
downward and forward, like a loose, half -filled sack. 
This is seen especially in persons who have been corpulent 
but who have lost a great deal of flesh, and in women after 
repeated confinements. It is the chief symptom of enter- 



DIAGNOSTIC TECHNIQUE. 3 

optosis, concerning which so much discussion has taken 
place since the publications of F. Glenard. This falling 
down of the abdomen has a real value in the special condi- 
tions which we have just specified ; it furnishes an indica- 
tion for the wearing of an abdominal belt, the support from 
which, without sufficing to cure, is nevertheless of great 
service to this class of patients. 

Palpation, percussion, and succussion afford informa- 
tion of the greatest importance with regard to diagnosis. 

By means of palpation we obtain information concern- 
ing the nature of tumors, whether true or false, and may 
also detect the presence of scybalous masses, so often mis- 
taken for neoplasms in constipated persons and more par- 
ticularly in the aged. By means of it also we examine for 
^edematous infiltrations, tumefactions, and painful points. 
Chapowsky has recommended in difficult cases that palpa- 
tion of the abdomen be made while the patient lies in a 
warm bath ; in this way we obtain a relaxation of the ab- 
dominal muscles, which greatly facilitates the examina- 
tion. 1 

We ought to examine systematically for movable or ac- 
tually floating kidney in all cases of nervous dyspepsia, 
especially when occurring in women ; this condition of the 
kidney is found much more frequently on the right side 
than on the left. 

We shall have to devote a little more time to a consid- 
eration of percussion, the practice of which requires the 
observance of certain special precautions when we have to 
do with the study of gastro-intestinal dyspepsia. 

First, as to percussion of the stomach, which is to be 
made in. the following way: the patient being on his back 
with the belly uncovered and the abdominal walls in a 
state of as complete relaxation as possible, percussion is 
made from above downward, following the mammary line 
from the lungs toward the stomach. In this way it is 
easy to map out the upper border of the stomach. As 
Malibran very justly observes, this border is often abnor- 
1 Wiener Medizinische Wochenschrift, No. 22, 1891. 



4 DISEASES OF THE STOMACH AND INTESTINE. 

mally elevated in gastro-intestinal atony and in flatulent 
dyspepsia. In percussing the semilunar space the reso- 
nance peculiar to the stomach in individual cases should 
be specially noted. The quality and tone of this resonance 
will give us often a very clear notion of the capacity and 
of the degree of distention of the stomach. In order to 
determine the lower border of this viscus it is necessary to 
percuss in the opposite direction from the side, or even 
from the iliac fossa, toward the stomach. Bearing in 
mind the peculiar resonance of the stomach, it is some- 
times easy to make out clearly the exact point where the 
intestinal resonance ceases and the gastric begins. In 
order to facilitate this examination we may distend the 
stomach by introducing first some bicarbonate of soda and 
then a solution of tartaric acid, or by insufflating air. 
This method of examination has found special favor in 
Germany. 

While conducting this examination .we note the reso- 
nance of the colon and also, by means of palpation and of 
succussion, determine the condition of this tube. 

Percussion is not always sufficient to enable us to map 
out the lower border of the stomach, and we must then 
resort to succussion to determine its location. 

Succussion.— We have to distinguish two forms of suc- 
cussion of the stomach, viz., digital and total, the latter 
of which may be called by way of distinction Hippocratic 
succussion of the stomach. 

The method of digital succussion has acquired consider- 
able importance since the publication of the works of Bou- 
chard and of his disciples on the subject of dilatation of 
the stomach. It is made in the following way: the pa- 
tient lying on his back with the abdominal muscles re- 
laxed, a series of rapid taps with the extremities of the 
fingers is made on the abdominal wall along a line running 
from the umbilicus to the edge of the false ribs on the left 
side. When a certain amount of liquid and of gas is pres- 
ent in the stomach we obtain in this way a sensation of 
splashing, to the existence and location of which Bouchard 



DIAGNOSTIC TECHNIQUE. 5 

attributes a pathological signification of great importance. 
When this sign is obtained a long time after a meal and 
especially in the morning, when the patient is fasting, it 
is an evidence that the stomach is not completely empty, 
but that it contains stagnant fluids which may become the 
seat of abnormal fermentation. This fermentation may 
give rise to the formation of toxic substances which in 
turn may be the cause of a chronic auto-intoxication, and 
of a sort of acquired diathesis which betrays itself by a 
great variety of morbid symptoms. 

The presence of a gastric succussion sound, when it is 
perceived below a line extending from the umbilicus to the 
border of the false ribs on the left side, indicates a perma- 
nent dilatation of the stomach. This sign is of special 
importance only when it is obtained a long time after a 
meal, and especially when the patient is fasting in the 
morning, no liquid having been taken at the moment of the 
examination. The corner-stone of the doctrine of gastric 
auto-intoxication is indeed permanent stasis of liquid in 
the stomach, and this stasis is shown to exist only when 
actual stagnation of the gastric fluids during fasting can 
be demonstrated (Debove). 

We must not confound splashing in the colon with that 
which occurs in the stomach, a mistake which has some- 
times been made. This confusion of the intestinal with 
the gastric noises explains doubtless those cases in which 
the passage of a tube and lavage of the stomach have failed 
to show the presence of fluid, although a splashing sound 
had been elicited by digital succussion. 

Hippocratic succussion, in our opinion, affords informa- 
tion of a more reliable character. It gives rise to a wave 
sound, the gastric or intestinal origin of which is easily 
distinguished by its character; its character and tone also 
enable us to judge of the dimensions of the cavity in which 
the wave is produced. 

If we base our diagnosis of dilatation of the stomach 
with permanent stasis upon an examination made only in 
the morning and when the patient is fasting, and especially 



6 DISEASES OF THE STOMACH AND INTESTINE. 

if we control the results of this examination by lavage of 
the stomach, we shall remarkably lessen the number of 
cases of true dilatation of this organ met with in practice. 
Dilatation with permanent stasis is moreover not a patho- 
logical entity; it is a common termination of different 
morbid conditions. The most opposite chemical processes 
may be found associated with it— hyperacidity, as well as 
a diminished production of hydrochloric acid. 

Examination of the large intestine is made in a general 
way on the same lines as examination of the stomach, and, 
mutatis mutandis, what has been said of the latter will 
apply equally to the former. 

In order to facilitate exploration of the colon, and to map 
out its borders, we may distend it by gas. Von Ziemssen, 
who was the first to advise this procedure, introduces into 
the rectum first a solution of bicarbonate of soda, and then 
one of tartaric acid. But it is simpler to introduce directly 
either carbonic acid gas already prepared, or air. The 
use of carbonic acid is preferred by some, for the reason 
that the irritation to the mucous membrane which this gas 
causes brings about a closure of the ileo-csecal valve, while 
air would enter the small intestine and distend its lower 
portion . 

In any case, before insufflation of the colon it is neces- 
sary to empty it by means of an evacuating enema. After 
this a red rubber catheter or stomach tube is introduced as 
far as possible into the rectum. The free extremity of this 
is attached to an insufflating apparatus, to an inverted 
siphon of Seltzer water, or to a cylinder containing liquid 
carbonic acid. The insufflation should be made slowly so 
as to produce a gradual dilatation, avoiding any sudden 
and exaggerated distention. 

The advantage of this method is that it allows us better 
to map out the limits of the colon, to differentiate it from 
the stomach, to determine with greater ease what its rela- 
tions may be with any abdominal tumor present, and also 
to determine whether it is the seat of a constriction. This- 



DIAGNOSTIC TECHNIQUE. 7 

method is rarely used in France at the present day, by 
reason, no doubt, of its possible dangers. 

Simon has recommended injection of water by the rectum 
as a method of diagnosis. When the patient is in the 
genu-pectoral position it is possible in the normal condi- 
tion to inject from two to five quarts of water through a 
high rectal tube; but in cases of narrowing of the lower 
part of the large intestine the quantity of water which can 
be introduced is much less. 

In order to judge better of the situation of certain ab- 
dominal tumors, Minkowski has recommended that the 
colon be filled with water and the stomach with gas. In 
this way we create two important landmarks for diagnostic 
purposes. 

II. Internal Examination Together with the 
Chemical Study of Gastric Digestion. 1 — The internal 
examination of the stomach is made by means of the 
elastic siphon, the employment of Kussmaul's pump hav- 
ing been entirely abandoned. This is the method of ex- 
amination devised by Leube. It teaches us the process by 
which the food is evacuated from the organ after a meal ; 
it also enables us to withdraw fluid from the stomach dur- 
ing digestion and to study it chemically. This study of 
the chemistry of the stomach, which was first undertaken 
in Germany several years ago, has been made the subject 
of numerous treatises, and is still much discussed. After 
a purely qualitative study of the gastric juice had been 
pursued for some time, various methods of quantitative ex- 
amination were proposed. The best of these is that em- 
ployed by Hayem and Winter. We are the more ready 
to accord this deserved praise because we shall be obliged 
later to discuss and reject a certain number of their con- 
clusions. Unfortunately the clinical study of the chemical 
changes occurring in intestinal digestion has not pro- 

1 It has been proposed by several writers to illuminate the cavity 
of the stomach by electricity, and to examine it either by trans- 
parency or by means of a tube provided with reflectors. (Reich- 
mann, Therapeutische Monatshefte, March, 1892.) 



8 DISEASES OF THE STOMACH AND INTESTINE. 

gressed as far as has that relating to the stomach. From 
this it follows that we still know but little of the conditions 
of intestinal digestion in various forms of dyspepsia, and, 
as the anomalies of gastric digestion are better understood, 
there is a tendency to attach an exaggerated importance 
to them. Against this tendency it is necessary to be on 
our guard. 

It is unfortunately hardly to be expected that we can 
add much in the near future to our knowledge of the diges- 
tive processes taking place in the intestine in the various 
forms of dyspepsia, by reason of the difficulties which a 




Fig. 1— Debove"s Tube. 

study of this kind presents. Since it is impossible to an- 
alyze the contents of the intestine in various morbid con- 
ditions, as we can those of the stomach, our only way is to 
analyze foods as they are ingested, to study the chemistry 
of the stomach, and then to determine the amount of the 
various excreta. In this study the methodical analysis of 
the faeces would be of the first importance. Unfortunately 
investigations of this nature demand not only the con- 
sumption of much time and the possession of complicated 
laboratory apparatus, but also a knowledge of practical 
chemistry which it is hardly in the power of ordinary 
physicians to possess. 

We are therefore forced to rely in our study of intes- 
tinal dyspepsia upon a few bald facts, as for example the 
existence of diarrhoea or of constipation, of tympanism, or 



DIAGNOSTIC TECHNIQUE. 



of pain. This is little enough, but nevertheless considera- 
ble progress has been made of recent years in our knowl- 
edge of the primary and secondary forms of gastrointes- 
tinal dyspepsia. 

But to return to the internal examination of the stomach 
bj T means of the elastic siphon, the method of practising 
which we shall examine in some detail. The passage of 
the sound is indeed the principal operation in the giving 





Fig. 2.— Fremont 1 s Tube. 

of a test meal, in washing out the stomach, and in forced 
feeding, all of which are of great importance in the diag- 
nosis and treatment of diseases of this organ. 

In the first place, what instrument shall we use? The 
red rubber tube, which Faucher was the first to use, and 
which Debove has since considerably improved, has wholly 
taken the place of the stomach pump. 

Debove's tube is perfectly smooth and semi-rigid and it 
is more easily introduced than is Faucher's tube. But we 
prefer to either of them the tube devised by Fremont of 
Vich}^, which is the one we ordinarily use. 

Fremont's tube is smooth like that of Debove and a little 



10 DISEASES OF THE STOMACH AND INTESTINE. 

less rigid. It is, however, stiff enough to enable it to pass 
readily the isthmus of pharynx, even in patients who have 
never submitted to the operation before. It is longer than 
the other tubes, and this increases the aspiratory power of 
the descending branch of the siphon. A small glass tube 
is inserted in its course, which enables us to see whether 
the fluids to be passed into or withdrawn from the stomach 
flow readily. This is especially useful when gavage is 
practised. Finally the gastric extremity of Fremont's 
tube is provided with a wide opening so that it is less easily 
pinched by the Avails of the stomach than are other tubes; 
and it is also more apt to remain patulous during the giv- 
ing of a test meal. We think less of other modifications 
of the tube devised by Fremont. For example, we do not 
regard his funnel as especially convenient, and alwa} T s em- 
ploy a funnel of the ordinary shape. And again, we almost 
never use the aspirator, ingenious as it is, which he lias 
attached to the siphon. We find expression sufficient 
for the extraction of the contents of the stomach. We 
shall see presently how this expression (Ewald's method) 
is carried out. 

Our method of introducing the tube into the stomach 
is as follows: the patient sits upon a chair with a rubber 
cloth tied about his neck, to prevent any possible soiling 
of the clothing. The sound is introduced boldly to the 
fauces, after being dipped in a little cold water. It is not 
necessary to grease it. Sometimes it is of advantage to 
depress the base of the tongue with the index finger of the 
left hand, so as to prevent the sound from touching 
the soft palate or tickling the uvula. The extremity of the 
tube should strike first against the posterior wall of the 
pharynx in an oblique direction, from above downward 
and from before backward. It is easily passed down to 
the sphincter situated at the level of the cricoid cartilage. 
At this point a slight resistance is occasionally felt, which 
can be overcome by a little firmness without the employ- 
ment of force. Indeed it is impossible, with a semi-flexible 
tube, like that of Fremont in particular, to use any undue 



DIAGNOSTIC TECHNIQUE. 11 

force. When this point has been passed the further prog- 
ress of the tube is very easy and it may be passed into the 
stomach without meeting with any obstacle, unless indeed 
there should be present a stricture of the oesophagus. By 
means of the scale marked on the tube we are always able 
to tell at just what point its extremity lies. 

It is well to give the patient certain instructions in ad- 
vance. He must be told not to close his teeth and to let the 
saliva flow freely from the mouth and fall on the cloth 
which will protect his clothing. He must further be told, 
and this is a matter of great importance, to breathe freely, 
strongly, and even audibly. Certain patients, especially 
when the tube is passed for the first time, stop breathing 
and become red, congested, even purplish, so that the 
physician may be led to fear that he has passed the tube 
into the larynx. In such a case the patient should be 
commanded sternly to make a deep inspiration. When 
that is done the congestion of the face will be seen to dis- 
appear, and the physician may then be certain, if he had 
any doubts before, that the tube is really in the oesophagus. 
We never perform either lavage or gavage without having 
taken the precaution to make the patient breathe freely. 
This is the best means of overcoming the fright which the 
passage of the sound provokes, and to restore the confidence 
of the patient. 

The introduction of the tube is made with a view of 
withdrawing the contents of the stomach by aspiration or 
expression, of washing out the stomach or of resorting to 
forced feeding. 

Aspiration is seldom employed. It may be effected in 
one of several ways : by attaching the open end of the tube to 
a bottle from which the air is withdrawn very gradually, by 
means of a Potain aspirator; or by attaching the tube to 
the first of two communicating flasks, the second flask 
being filled with water and placed at a lower level than 
the first. Aspiration is effected by letting the water flow 
from the second flask. One may also make use of a spe- 
cial aspirating attachment devised by Fremont. 



12 DISEASES OF THE STOMACH AND INTESTINE. 

Usually, however, it is not necessaiy to resort to aspira- 
tion, the method of expression being sufficient to cause the 
withdrawal of the fluids of the stomach, and even, in some 
cases, to effect the complete evacuation of the organ. This 
method, called Ewald's expression, is performed in the 
following way : The sound being introduced, whether dur- 
ing fasting or after a test meal (see below), the patient is 
told to cough. He ought to cough especially with the dia- 
phragm, in such a way as to cause a series of blows against 
the stomach. This suffices in most cases to fill the tube, and 
the gastric fluids then flow out on the principle of siphonage. 

We should not forget that there is a general tendenc} T to 
introduce the tube too far, and we may often obtain a flow 
of the fluid by withdrawing it a little. Sometimes by 
making successive to-and-fro movements of the tube we 
provoke efforts of vomiting, and, if the tube is not inserted 
too deeply, this expulsion of the contents of the stomach 
takes place through its lumen and the desired end is ob- 
tained. This is another reason why it is better to have a 
tube with a wide opening, provided not only with lateral 
eyes but also with a terminal opening of the diameter of 
the tube itself. 

In practising lavage water is poured into the funnel and 
the latter is elevated bo that the fluid flows into the stom- 
ach. Before the tube is completely emptied the funnel is 
rapidly lowered, in such a way that the tube is converted 
into a siphon and the water, more or less mixed with gas- 
tric juice and alimentary detritus, flows back through it. 
The same manoeuvre is repeated several times until the 
lavage has been carried as far as necessary. 

In case of forced feeding (gavage) it is necessary to pro- 
ceed rapidly, to be sure that the patient is breathing well, 
and that all the liquid which has been poured into the 
funnel has been passed into the stomach. If this is not 
done there is danger that a part of the liquid may enter 
the laiynx. In order that we may be sure that the tube 
is "ompleteh- empty it is well to have it provided with a 
glass window as in Fremont's apparatus. 



DIAGNOSTIC TECHNIQUE. 13 

We insist upon all these details because upon a knowl- 
edge of them depends often the success of tubage of the 
stomach and of the operation which it is proposed to per- 
form, whether exploration, the giving of a test meal, forced 
feeding, or lavage. 

Chemical Examination of the Contents of the 
Stomach. — The fluids withdrawn during fasting may be 
examined at once. But in most cases the stomach com- 
pletes its task within six or eight hours after a normal meal 
(Leube), and after that time is entirely empty, so that, in 
order to obtain any fluid, the exploration must be made 
during digestion. The meal given with this special end. 
is called a test meal. Leube gave a sort of test breakfast, 
similar to an ordinary breakfast, and examined the stom- 
ach from five to eight hours after this repast, with the ob- 
ject of determining how long it takes the organ to empty 
itself completely. This is one of the best means of judg- 
ing concerning the degree of motility of the stomach. 

When it is desired to make a chemical examination of 
the contents of the stomach a meal of this kind would be 
unsuitable, for digestion is at its height rather late, and 
furthermore the withdrawal of the fluids would often be 
rendered difficult by clogging of the tube with alimentary 
detritus. On this account a much more simple and less 
copious test meal is usually given. One of the most com- 
monly employed is Ewald's, which consists of 60 grammes 
of stale bread and 250 grammes of weak tea or water. The 
contents of the stomach are then removed at the end of an 
hour, counting from the time the first mouthful is taken. 

This meal is excellent when it is desired to study the 
condition of secretion of the gastric mucous membrane, or 
to procure some of the gastric juice with a view to its ex- 
amination by Winter's methods or by artificial digestion 
in a test-tube. It is of much less value when it is a ques- 
tion of investigating and determining the importance of 
secondary acid fermentations. In such a case it would be 
better to make use of a more complicated meal containing 
eggs or meat. And then it will be necessary to delay the 



14 DISEASES OF THE STOMACH AND INTESTINE. 

moment of examination so that it may coincide with the 
period of maximum secretion and digestion. 

How is the chemical examination of the contents of 
the stomach which have just been extracted to be made? 
We shall content ourselves with a description of the 
method which a long experience has led us to believe to 
be the best, without referring to the great number of other 
methods which have been proposed. 

The fluids removed must first be filtered. It is incorrect 
to assume that the slowness of filtration is a measure of 
the richness of the gastric juice in mucus. Indeed Hallo- 
peau and myself have noticed that the products of artificial 
digestion filter the more slowly the greater the proportion 
of albuminoid substances and especially of peptone which 
they contain in solution. 

We begin by estimating the total acidity. For that 
purpose a solution of caustic soda of the strength of four 
parts to the thousand (deci-normal solution) is necessary. 
A cubic centimetre of this solution corresponds to 3.65 
milligrammes of hydrochloric acid. This solution is added 
drop by drop from a graduated burette to a test-tube con- 
taining 10 cubic centimetres of filtered gastric juice, to 
which a few drops of an alcoholic solution of phenol- 
phthalein have been added. The completion of the opera- 
tion is marked by the appearance of a beautiful bright red 
coloration, due to excess of the alkaline base. 

Phenol -phthalein is frequently employed as a reagent 
in estimating the acidity of the gastric juice ; but it is 
much better to employ litmus for this purpose. By means 
of this we obtain results apparently indicating a smaller 
amount of acid than we do when using phthalein; but 
neither peptones nor xanthin, hippoxanthin, etc., should 
be counted in estimating the total acidity. Furthermore, 
in estimating the proportion of free acids by Gautier's 
method, we have to use litmus. And when we employ 
phenol-phthalein to determine the total acidity and litmus 
to show the amount of organic acidity, the figures given 
by the latter are always too high. 



DIAGNOSTIC TECHNIQUE. 15 

A relatively simple manoeuvre (A. Mathieu and Remond) 
enables us to measure very exactly the quantity of fluid 
contained in the stomach. After a certain quantity of 
gastric juice has been withdrawn from the stomach a 
measured quantity of distilled water is added to it ; this 
diluted gastric juice is poured back into the funnel and 
then passed into the stomach, so that the mixture may be 
complete. As much as possible of the diluted gastric juice 
is then withdrawn and collected in a special receiver. Let 
b represent the undiluted fluids withdrawn, a the acidity 
of this liquid, a' the acidity of the diluted liquid, q the 
quantity of distilled water introduced into the stomach. 
The amount of acid being evidently the same in the diluted 
liquid as in that to which no water has been added, we 
obtain the following equation : 

ax = ci q-\- a' x. 

which is equivalent to 

a' q 
x = ~- 

a — a 

The quantity of liquid originally contained in the stomach 
is then represented by the formula : 

7i a ' Q 
a — a 

This very simple formula enables us to determine exactly 
the amount of liquid contained in the stomach at the time 
of examination, information which may be useful under 
many circumstances and from many different points of 
view. Of special value is the fact that this method allows 
us to refer the figures obtained, not to a hundred or a 
thousand parts, but to the total amount of liquid contained 
in the stomach. The absolute figures representing the 
proportion of acid and of chlorine naturally furnish in- 
formation concerning the condition of digestion which is 
much more exact than that obtained by a mere knowledge 
of the percentage would be. 

Qualitative Examination of the Gastric Juice. — At 
first coloring reagents were employed to determine the 
presence or the absence of hydrochloric acid in the gastric 



16 DISEASES OF THE STOMACH AND INTESTINE. 

juice. Originally methyl-violet was used, which turns 
from violet to blue in the presence of even a verj' minute 
trace of a free mineral acid. Many other qualitative re- 
agents have been proposed. Uffelmann's reagent was 
used especially to determine the presence of lactic acid. 
One or two drops of perchloride of iron are added to 100 or 
150 grammes of a one-per-cent solution of phenic acid; the 
solution acquires an amethyst or violet color. This color 
passes into that of yellow urine in the presence of a weak 
solution of lactic acid ; but the solution decolorizes in the 
presence of hydrochloric acid. This reaction is only of 
slight importance and is moreover liable to give rise to 
error. Gimzburg's phloroglucin-vanillin test is an ex- 
cellent one for the qualitative estimation of hydrochloric 
acid. The following is the formula for this reagent : 

Phloroglucin, 2 grammes. 

Vanillin, 1 gramme. 

Alcohol, ...... 60 to 100 grammes. 

A small quantity of this solution is gently heated over 
a water bath or over an alcohol lamp in a porcelain dish. 
A little of the gastric juice is added and the mixture is 
again heated. When free- hydrochloric acid exists a very 
characteristic bright carmine ring appears in the porcelain 
dish before desiccation is complete. 

Personally we use only ethyl-green, which is full}' as 
sensitive as Gunzburg's reagent and much more easily 
employed. 

The solution should be made in distilled water ; by rea- 
son of the enormous coloring power of ethyl-green powder, 
only a very small amount is required, about half a tea- 
spoonful for a litre of distilled water. The solution thus 
obtained is not green but blue. In the presence of a small 
proportion of free hydrochloric acid the solution turns 
a grass-green; of H to 2 parts per 1,000, a yellowish 
green; of 2i to 3 parts per 1,000, the color of dead leaves. 
But this is not all; for the solution to which hydrochloric 
acid or gastric juice containing this acid has been added 



DIAGNOSTIC TECHNIQUE. 17 

decolorizes with a rapidity which is the more marked in pro- 
portion as the quantity of acid is greater. A very much 
larger quantity of organic acids (3 or 4 parts per 1,000 of 
lactic acid) is required to produce a grass-green color, such 
as is obtained with one part per thousand of hydrochloric 
acid, and furthermore there is no decolor izati on later. 

Ethyl-green is therefore an excellent reagent, and in 
many cases it permits of a chemical diagnosis sufficiently 
accurate to enable us to undertake a treatment based upon 
the cause of the trouble, provided the total acidity has been 
previously determined. Let us suppose, for example, that 
the total . acidity is from 2i to 3+ parts per 1,000 and that 
the green reaction is very marked and its final disappear- 
ance is rapid and complete, then there is no doubt that hy- 
drochloric acid is present. If the fluid examined has been 
obtained in the morning from a dilated stomach, the pa- 
tient being fasting, there is continuous hypersecretion and 
dilatation of the stomach with stasis of its contents. If, 
on the other hand, the total acidity is weak (1^ to 1 per 
1,000 or less), the green reaction is absent or doubtful and 
there is no final decolorization, then we have to do with 
an insufficient secretion of hydrochloric acid. A moderate 
acidity (1.6 to 2 parts per 1,000) combined with an evi- 
dent green reaction affords probable evidence of a condi- 
tion approaching the normal. Evident gastric stasis, high 
total acidity (2 to 3 parts per 1,000), and an absence of a 
green reaction point to dilatation of the stomach with stasis 
and abnormal acid fermentation. 

We see therefore that a determination of the total acidity 
together with a qualitative examination of the gastric juice 
may serve to solve many diagnostic problems. The results 
obtained are, however, inferior to those which Winter's 
method gives, but as an offset to this the latter requires a 
more complicated apparatus and the consumption of much 
more time. It possesses the advantage of being not quali- 
tative but quantitative, proportionally quantitative at least. 
It enables us to determine the quantity not only of free 
hydrochloric acid in the gastric juice, but also of the com- 
2 



18 DISEASES OF THE STOMACH AND INTESTINE. 

bined hydrochloric acid. We learn thus the total amount 
of this acid furnished by the stomach, and obtain thereby 
much more accurate information concerning the physio- 
logical and even the anatomical condition of the gastric 
mucous membrane. 

Winter's Method. — The gastric juice is filtered, and its 
total acidity is determined b} T the procedure above de- 
scribed. Five cubic centimetres of this filtered juice are 
poured into three porcelain capsules, numbered 1, •>, and :>. 
To the contents of capsule No. 1 an excess of carbonate 
of soda is added. The three capsules are then evaporated 
to complete dryness over a water bath. An excess of car- 
bonate of soda in solution is now added to capsule No. 2 
and the contents are again evaporated to dryness. The 
three capsules are then calcined over a Bunsen burner, but 
the heat should not be carried too far, the calcination being 
arrested when there are no more points of ignition. To 
capsules Nos. 1 and 2 a slight excess of pure nitric acid is 
added, and then some distilled water; this is boiled and 
thrown on to a filter. Capsule No. 3 is treated with boil- 
ing water simpry, and this water is also thrown on to a 
filter. 

The amount of alkaline chlorides contained in the liquid 
thus prepared is calculated by nitrate of silver in the pres- 
ence of j T ellow chromate of potassium as a reagent. First 
the excess of nitric acid is saturated by pure carbonate of 
lime, then a few drops of a ten-per-cent solution of yellow 
chromate of potassium are added, and finally a deci-nor- 
mal solution of nitrate of silver is added a drop at a time. 
The end of the operation is indicated by the appearance 
and especially by the persistence of a brownish-red colora- 
tion. A cubic centimetre of the deci -normal solution of 
nitrate of silver corresponds to 3.05 milligrammes of hy- 
drochloric acid. The chlorine is also valued as hydro- 
chloric acid. 

What has taken place, and what is the significance of 
the figures obtained? In capsule No. 1 the free hydro- 
chloric acid and that existing in combination have been 



DIAGNOSTIC TECHNIQUE. 19 

fixed by the carbonate of sodium as chloride of sodium ; 
the chlorine found by analysis corresponds therefore to the 
total chlorine of the gastric juice. In capsule No. 2 the free 
hydrochloric acid has been dissipated by evaporation ; the 
difference between the contents of the two capsules there- 
fore represents the free, or rather the volatile, hydrochloric 
acid in the gastric juice examined. In capsule No. 3 the 
free hydrochloric acid has been evaporated and the acid in 
organic combination has been destro}^ed by calcination 
and dissipated ; there remains then only the chlorine of the 
mineral chlorides, that is to say, the fixed chlorine. The 
difference between the chlorine in capsule No. 2 and that 
in capsule No. 3 indicates the quantity of chlorides de- 
stroyed by calcination, or, in other words, chlorine in or- 
ganic combination. 

We obtain thus the following data calculated for 1,000 
parts of the gastric juice : 

1. The total chlorine, T. 1 

2. Free hydrochloric acid, H. 

3. Chlorine in organic combination, C. 

4. Fixed chlorine (the chlorine of the mineral chlor- 
ides). 

H + C represents the total quantity of hydrochloric acid 
secreted by the stomach. It is by far the most important 
information furnished by Winter's method. It should be 
remarked that it represents the difference of the figures of 
capsules 1 and 3. We may then, when employing a quali- 
tative test, especially ethyl-green, dispense with an esti- 
mation of the amount of chlorine in capsule No. 2. It is 
the examination of the contents of this capsule that de- 
mands most time, for it has to be evaporated twice. 

Hayem and Winter endeavor to obtain by their method 
information concerning the quality of digestion and the 
richness in organic acids of the gastric juice. They do 
this in the following way : they subtract from the total 
acidity the acidity due to free hydrochloric acid, A — H, 
and compare the result with the chlorine in organic com- 
1 These letters are those used bv Hayem and Winter. 



20 DISEASES OF THE STOMACH AND INTESTINE. 

\ IT 

bination : - — ^ — = «• Now in the normal state a = 0.86 

nearly, because C is then always more than A — H. If a 
is above the physiological mean it indicates, say Hayem 
and Winter, that the organic acids are present in consid- 
erable quantity in the gastric juice. If, on the contrary, 
a is below the normal it is an evidence that an exaggerated 
amount of chlorine is present in combination with sub- 
stances of organic origin under the form of a neutral or 
alkaline combination. This indicates a vicious chemical 
process, the chloro-organic combinations formed by the 
direct action of hydrochloric acid on albuminoid substances 
being always acid. Unfortunately the matter is much 
more complex than that. The total acidity of the gastric 
juice, especially when it is measured by the phenol-phtha- 
lein test, is the sum of the acidity of various substances, 
some known, others unknown ; and we are ignorant as to 
what are the principal factors of this acidity. As to the 
chloro-organic compounds we know almost nothing of their 
nature, for how can we determine the significance of the 
quotient when both dividend and divisor are themselves 
incompletely determined? 

This is not the place to criticise in further detail this 
particular point. What we have just said will suffice to 
show that the chemical analysis of the gastric juice by 
Winter's method gives certain results which are of value 
only as bearing upon the secretion of hydrochloric acid, free 
or combined, by the gastric mucous membrane. It is, 
however, true that it gives much more exact information 
than any of the other methods, and that this information is 
sufficient to serve as an indication for treatment. 

The secretion of pepsin is in general proportionate to 
that of hydrochloric acid, although this rule is not abso- 
lute ; for a certain gastric juice may be very rich in hydro- 
chloric acid and yet not necessarily very rich in pepsin. 
It is indeed not very rare to find that a hyperacid gastric 
juice will peptonize in the test-tube only a very small 
amount of albumen. We can only judge of the value of 



DIAGNOSTIC TECHNIQUE. '21 

this secretion in an indirect manner, by qualitative or 
quantitative estimation of the peptone and by artificial 
digestion. 

The qualitative estimation of peptone is made by what is 
called the biuret method; Fehling's solution may be used. 
To a urinary test-tube containing two or three cubic centi- 
metres of filtered gastric juice, a few drops of Fehling's 
solution are added. If there is anj T peptone or propeptone 
present a rose color is obtained, which is the more marked 
in proportion as the quantity of peptone is greater. The 
albuminoid substances, when present, produce a purplish 
coloration. Quantitative estimation of peptone is a very 
delicate matter, demanding too careful manipulations to 
be described here. 

Artificial digestion is easily accomplished when one 
has an oven the temperature of which can be maintained 
at 40° C. (103.5° F. ). The substance used for digestion is a 
determined quantity of hard-boiled white of egg, which is 
kept in the oven for twenty-four hours. A certain amount 
of hydrochloric acid may be added. It is easy in this way 
to determine approximately the value in pepsin of any 
special sample of gastric juice. This method, which was 
formerly much employed, has now fallen somewhat into 
disuse, notwithstanding its real value. 

Determination of the Organic Acids. — In general, 
when there is marked acidity, with little free or combined 
hydrochloric acid present, we must assume that the gas- 
tric' juice contains a proportionately large amount of acids, 
derived from organic fermentation. 

Professor Gautier has proposed an ingenious method for 
estimating the amount of free or combined organic acids. 
The acidity of the sample specimen of gastric juice to be 
examined is exactly saturated by soda ; this is precisely the 
operation undertaken for the estimation of total acidity. 
The gastric juice thus neutralized is evaporated to dryness 
over a water bath, and is then calcined as in Winter's 
method. The residue, after calcination, is treated by boil- 
ing water ; we thus obtain an alkaline solution. The alka- 



22 DISEASES OF THE STOMACH AXI) INTESTINE. 

Unity of this solution is then measured by a standard 
deci-normal solution of sulphuric acid. The figures thus 
obtained represent a quantity of organic acids, free or com- 
bined, which have been destroyed by calcination. Indeed 
the addition of soda transforms the organic acids, free or 
in feeble combination, into the corresponding salts (lactate, 
acetate, etc.), and calcination reduces them to the condi- 
tion of alkaline carbonates. In estimating the amount of 
these alkaline salts by sulphuric acid, we are able to de- 
termine what amount of organic acids they were combined 
with. 

This estimation of the quantity of organic acids enables 
us to measure the amount of organic fermentation in the 
stomach and to determine whether this fermentation is 
weak, normal, or excessive. We have said above that in 
many cases the simple estimation of the total acidity and 
the employment of the ethyl-green test suffice to give 
information of a certain value concerning this organic 
fermentation. 

One remark in conclusion : the estimation of the alka- 
linity of the solution obtained after calcination ought to 
be made in the presence of litmus; indeed we cannot re- 
trace our steps after the use of phenol-phthalein and obtain 
a play of colors progressively from red to white. We 
ought then, in order to have comparable results, to use 
litmus also in estimating the total acidity. 

We need say nothing of the examination for rennet, 
which, up to the present time at least, has not been shown 
to possess any clinical value. 

The knowledge which we yet have concerning the chemi- 
cal processes of gastric digestion is very incomplete. 
Xevertheless it may serve as a foundation for a clinical 
classification of the different varieties of gastric dyspepsia 
and may furnish very important indications for their 
treatment. We know unfortunately even less concerning 
intestinal digestion, and it is only indirectly, by examina- 
tion of the excreta, that we can judge of the condition of 
the secretions and of the digestive work performed by the 



DIAGNOSTIC TECHNIQUE. 23 

intestine and its appendages. Boas has, however, devised 
a method of extraction by means of which we may some- 
times obtain the duodenal juice by way of the stomach. 
He has in this way obtained a liquid which is capable of 
peptonizing albumen in an alkaline medium, and which 
contains therefore pancreatic juice. Up to the present time 
this procedure has not given us any data which may be of 
service from a diagnostic or therapeutic point of view. 

Gastric Motility. — It would be a matter of the great- 
est importance to be able to measure the motility of the 
stomach, and investigators have not been wanting who 
have applied their ingenuity in efforts to solve this prob- 
lem. Indeed it is of little use to know the compolition of 
the contents of the stomach, if we do not know to what 
degree the viscus empties itself, for we cannot then esti- 
mate its total work; and in fact we do not know how to 
measure this work. It is then difficult to apportion the 
blame to the stomach and intestine for the failure of nutri- 
tion which may result from a morbid condition of either 
of these organs, for we are unable to determine the pre- 
cise relative degree of responsibility of these two organs in 
dyspepsia. 

We know, however, that a weakened motility of the 
stomach leads to gaseous distention, to stasis of the liquids, 
and to abnormal fermentations. We have already said 
how a diagnosis of flatulence and stasis is made. Other 
very ingenious methods have been proposed for determin- 
ing the degree of motility of the stomach, which we cannot 
completely pass over in silence. 

Effervescent mixtures (bicarbonate of soda and tartaric 
acid) may be injected into the stomach and into the large 
intestine. From the distention thus obtained we may 
more readily determine the relative situation of these or- 
gans, and the degree of this distention may serve to indi- 
cate the degree of tonicity of their muscular walls. 

Klemperer introduces a certain quantity of oil (150 to 
200 grammes) and at the end of one or two hours he evac- 
uates the contents of the stomach. The quantity of oil 



24 DISEASES OF THE STOMACH AND INTESTINE. 

recovered is inversely proportional to the motor power of 
the stomach. This procedure, which is open to serious 
objections, is rather frequently emplcwed in Germany. 

Ewald and Siewers have proposed the salol test. This 
substance has the property of not resolving itself into sali- 
cylic acid and phenol except in the presence of the pan- 
creatic juice, and is accordingly not acted upon at all in the 
stomach. When atony and gastric stasis are present the 
salol will remain for a long time in the stomach, and be- 
cause of its late arrival in the duodenum is split up only 
after a considerable interval; as a consequence of this its 
appearance in the urine will be much more tardy in the 
case of gastric atony or stasis than in healthy individuals. 
It has been objected to this tost that the important point 
is not the moment of the appearance of salicylic acid in 
the urine, 1 but rather the persistence of its elimination by 
the kidneys. It has also been said, and this would take 
away all value whatever from the salol test, that the split- 
ting up of the drug may take place in the stomach as well 
as in the duodenum." The method is therefore more ele- 
gant than sure. 

The best and most certain way is. however, to determine 
the time after a meal during which the alimentary sub- 
stances remain in the stomach; this is, in fact, Leube's 
original method. We have already explained how much 
importance attaches to the finding of the remains of food 
in the stomach in the morning while the patient is tasting. 

III. The Study of Excreta. — These excreta are the 
urine and fa3cal matter. They have been only too rarely 
studied together and thoroughly in cases of disease of the 
digestive apparatus. Researches of this nature, long and 
troublesome it is true, would certainly give interesting re- 
sults. We know what important facts bearing upon gen- 

'Tbis appearance is indicated by a very marked reaction: the 
addition of a few drops of perchloride of iron produces a very in- 
tense deep red color. 

2 Reale and Grande : " On the Decomposition of Salol in the Stom- 
ach, " Rivista Clinica e Terapeutica, October, 1891. 



DIAGNOSTIC TECHNIQUE. 25 

eral pathology and diagnosis Bouchard has drawn from a 
study of the organic poisons contained in faecal matter 
and urine. 

Van Noorden 1 has made some experiments in the way 
of estimating the amount of nitrogen contained in the in- 
gested matters, in the faeces, and in the urine. He suc- 
ceeded by this means, in certain cases, in getting an idea 
of the actual condition of the total digestion of albuminoid 
substances. One of the most striking results which he ob- 
tained in this way was the demonstration of the fact that 
certain individuals, whose gastric digestion left much to 
be desired, nevertheless elaborated the nitrogeneous foods 
in the end in a normal way — a new proof that our various 
methods of examination of the stomach give us information 
concerning the anatomical condition and the physiological, 
chemical, and motor functions of the stomach, rather than 
concerning gastro-intestinal dyspepsia in its entirety. The 
facts which we are able to deduce from it are of much 
greater service in the way of an anatomico- physiological 
diagnosis of the condition of the gastric mucous membrane 
than as a measure of the degree of dyspepsia as a whole. 

It was natural to look to a study of the urine as a means 
of obtaining information concerning the state of the di- 
gestive processes in the stomach and intestine; we shall 
presently show briefly in what that consists. 

The study of the faeces has only been begun. Formerly 
it consisted in a simple macroscopic examination, in ob- 
serving whether diarrhoea or constipation existed — an 
examination en bloc, so to speak; in certain cases the ap- 
pearance of pus, blood, bile, or mucus forced itself upon 
the attention of the observer. The clinical estimate so 
formed is necessarily very gross, and it is astonishing that 
the faeces have not been made the subject of more accurate 
study, both chemical and microscopical. Physicians have 
not ordinarily, it is true, the time to devote to these 
tedious and repugnant researches, and to this cause is 
doubtless due the regrettable poverty of scientific material 
^eitschrift fur klinische Meclicin, 1890. 



26 DISEASES OF THE STOMACH AND INTESTINE. 

bearing upon this important semeiological point. We owe 
to Nothnagel, 1 however, some interesting facts to which 
we shall refer later. It is not the place here to enter upon 
long details of this sort, for we must not forget that we 
are addressing practitioners. We would refer them in a 
general way, in the matter of technique, to special trea- 
tises and more particularly to those which have to do with 
the examination of the urine; we shall content ourselves 
with noting here briefly the results obtained and their 
value in a diagnostic sense, and shall be very sparing in 
our presentation of the technique of this order of investi- 
gations, which of necessity demand more or less special 
training. 

The Urine. — In regard to the urine, which is always 
examined in the usual way for albumin, sugar, etc., we 
may determine : The total quantity, the total acidity, its 
richness in urea, in chlorides, mid phosphates, in toxic 
substances, and in indican, phenol, etc. 

Quantity of the Urine. — The urine is greatly diminished 
in quantity or even suppressed in cases of abundant vom- 
iting, in profuse diarrhoea, gastro-intestinal hemorrhage, 
or occlusion of the intestine high up. After attacks 
of vomitingor gastric crises in neuropathic individuals, in 
the hysterical especially, we often note the appearance of 
polyuria — a point that may be not without a certain value 
in the diagnosis of nervous gastric affections. 

Acidity of the Urine. — This is estimated in the same 
way as is the acidity of the gastric juice, the sample of 
urine tested being one taken from the total amount passed 
in the twenty -four hours, for the acidity varies much at 
different periods of the day. The same is true also of the 
chlorides and of the urea, and this fact must not be for- 
gotten if we would obtain figures of any value whatever. 

There seems to be a sort of balance between the acidity 
of the gastric juice and that of the urine, and when the 
gastric juice is removed artificially by the tube or naturally 
by vomiting the urine becomes alkaline. The acidity of 

1 "Beitrage zur Physiologie und Pathologie des Darmes, " 1884. 



DIAGNOSTIC TECHNIQUE. 27 

the secretion is, on the other hand, increased when that of 
the gastric juice is diminished, and furthermore, accord- 
ing to certain writers, there is then an absence of the daily 
variations of acidity and alkalinity which take place in 
the normal state. The urine ordinarily becomes alkaline 
two or three hours after a meal, its acidity returning only 
after five or six hours. 

According to Sticker and Htibner ' we may, as a result 
of the examinations for acidity, draw the following con- 
clusions : 

a. An alkaline condition of the urine after lavage of the 
stomach or vomiting affords a presumption of hyperacidity 
or hypersecretion ; an absence of variation indicates in like 
case an acidity of organic origin. 

b. An absence of variation in the reaction of the urine, 
or an increase of its acidity some time after a large meal, 
is an indication of an insufficient quantity or of an absence 
of hydrochloric acid in the stomach. 

Total Urea. — The quantity of urea excreted during the 
twenty-four hours with normal diet, which is neither too 
rich nor too poor in albuminoid substances, may furnish 
information of a certain value in diagnosis. In cases of hy- 
persecretion of hydrochloric acid there is in general, when 
vomiting is not too profuse, an increased amount of urea 
in the urine. The presence of a normal quantity of urea in 
a case of hyperacidity in which emaciation has occurred 
indicates that the digestion of albuminoid substances is 
taking place in a satisfactory way, notwithstanding the 
poverty of the gastric juice in hydrochloric acid. 

In cases of cancer in which the evolution of the disease 
has advanced rather far there is, in the majority of in- 
stances, a marked diminution in the quantity of urea 
eliminated (G. Rauzier). 2 A diminished amount of urea 
furnishes therefore only a probability of cancer, of cancer 
of the stomach in particular, and is not a pathognomonic 

1 Zeitschrift fiir klinische Medicin, Band 7. — Supplement Heft, 
p. 25 (quoted by Boas). 

2 These de Montpellier, 1889. 



28 DISEASES OF THE STOMACH AND INTESTINE. 

sign as Rommelaere has claimed. An individual may 
indeed have a diminished secretion of urea without being 
cancerous, or may be cancerous and at the same time have 
a normal secretion of urea. 

Chlorides. — Profuse vomiting reduces markedly the 
quantity of chlorides eliminated in the urine, a fact that 
is easily explained. Bouveret has thought that an increase 
in the relative proportion of urea and of the chlorides is a 
diagnostic sign of hypersecretion of hydrochloric acid. In- 
stead of 2.3 which is the normal proportion, 1 the figures 
may be markedly increased. We do not think that this 
has any more value than the simple fact of the richness of 
urine in urea. 2 

Phosphates. — The presence of phosphates is of no more 
value for the diagnosis of cancer of the stomach than is 
that of urea. Urine rich in phosphates is frequently found 
in neuropathic subjects and consequently in dyspeptics. 
Such urine becomes turbid on cooling and clears up when 
heated. 

Toxic Substances. — An odor of sulphuretted hydrogen 
has sometimes been noticed in the urine. This odor may 
be due to the putrefaction of this fluid (Miiller). Less fre- 
quently (Bezt, Senator) sulphuretted hydrogen of intestinal 
origin has been found in urine which has not undergone 
putrefaction. In the case reported by Senator there were 
signs of marked indigestion with collapse. 8 

The presence of a notable quantity of sulpho-acids in the 
urine would indicate that there is an excessive process of 
putrid fermentation going on in the digestive tube. The 
methods of examination for these acids are too complicated 
to be described here. The same is true of the determina- 
tion of the toxic quality of the urine, a process which can 
only be carried out in a properly fitted-up laboratory. 

1 25 grammes of urea to 11 grammes of chlorides. 

2 A. Mathieu and L. A. Hallopeau : Societe medicale des hopi- 
taux, December, 1891. 

3 H. Leo : "Diagnostik der Krankheiten der Verdauungsorgane, " 
p. 293. 



DIAGNOSTIC TECHNIQUE. 29 

Indican, Phenol, Paracresol, etc. — We are able to 
demonstrate in the urine in certain cases the presence of 
aromatic substances, which owe their origin to the putrid 
decomposition of albuminoid substances ; these are indol, 
phenol, paracresol, etc. 

Indol is eliminated from the urine under the form of in- 
dican, the qualitative determination of which is very easy. 
Its presence in considerable amount indicates marked pu- 
trid fermentation in the intestine. This occurs in certain 
cases of constipation or of diarrhoea, especially in intestinal 
occlusion, in cancer of the stomach, and in purulent peri- 
tonitis. It has been asserted that indican is absent from 
the urine when the pancreatic digestion of albuminoid 
substances is insufficient. This is perhaps true in a cer- 
tain number of cases ; but indican is so often absent from 
the urine that it is impossible to attribute any special value 
to this sign. And on the other hand Thiroloix has shown 
that indican may be present in the urine of dogs from 
whom the pancreas has been removed. 

To determine the presence of indican, 10 cubic centi- 
metres of hydrochloric acid and about 1 cubic centimetre 
of chloroform are added to 10 cubic centimetres of urine. 
Then one or two drops of a concentrated solution of chloride 
of calcium are added by means of a glass rod ; the mixture 
is shaken, and if indican is present the chloroform assumes 
a blue color in consequence of the indigo which has been 
formed. An excess of chloride of calcium hinders the pro- 
duction of this reaction. When the urine contains a trace 
of iodides an intense red color is produced ; this is an ex- 
cellent test for the iodides. 

According to J. Munk, 1 man eliminates through the 
kidneys in health 0.017 to 0.051 gramme of phenol and of 
paracresol. In pathological conditions this amount may 
be increased to 0.31 or even to 0.63 gramme. This is some- 
times seen in cases of ileus, of dilatation of the stomach, 
and of cancer of the stomach or rectum. 

Fceces. — Special chapters will be devoted to a considera- 
1 Leo, loc. cit. , p. 317. 



30 DISEASES OF THE STOMACH AND INTESTINE. 

tion of constipation and of diarrhoea. We shall concern 
ourselves in this place only with the physical and chemical 
study of the faecal matters, such as can be made by direct 
examination by the microscope, or with the aid of very 
simple chemical manipulations. We shall omit in this 
brief presentation everything which has no bearing on 
dyspepsia or on gastro-intestinal diseases. We shall in- 
dicate the means by which it is possible to detect in faecal 
matters the presence of fat, of starch, of undigested ali- 
mentary detritus, of bile, mucus, pus, and blood, and show 
what their semeiological signification may be. 1 

Fat. — Fatty stools ma}' appear under different forms. 
Sometimes they are solid, being made up of fat in great 
quantity, or they may be softened under the influence of 
heat. Sometimes the}' are seen to contain fat clots of 
greater or less size. In liquid stools we often see little 
drops of fat floating on the surface, the drops varying 
in size from mere whitish or grayish points to collections 
the size of a grain of rice or of a pea. The fat may be ex- 
amined under the microscope or chemically. 

Under the microscope it may be seen as little drops of 
pure fat, as crystals of fatty acids, or as colorless or yellow- 
ish clots. The fatty drops, which are easy of recognition, 
are seen when the patient has been on a milk diet, or after 
the use of cod-liver or castor oil. When they are very nu- 
merous they indicate defective resorption of fat (fatty 
diarrhoea of nursing infants). The crystals found may 
be either crystals of fatty acids which melt when gently 
warmed, or saponaceous crystals which do not melt with 
heat ; the first are soluble in ether, the second are not. 

According to M tiller, 2 the presence in the stools of a large 
quantity of fat crystals is an indication rather of an im- 
perfect resorption of fat than of a vitiation of the pancrea- 
tic secretion. A large number of these crystals are found 
in patients who have no lesion of the pancreas, in those 

1 Nothnagel : " Beitrage zur Physiologie und Pathologie des Dar- 
mes." H. Leo, loc. cit., Berlin. 1884. 

2 Zeitschrift fur klinische Medicin, Bd. xii., p. 45. 



DIAGNOSTIC TECHNIQUE. 31 

with jaundice, and especially in patients in whom there 
exists an obstacle to resorption by the chyliferous vessels, 
as in diseases of the peritoneum and of the mesenteric gan- 
glia, for example. 

The clots sometimes found are formed of neutral fat, 
most frequently with a lime base ; they melt under the in- 
fluence of heat, and are reduced to pure fatty acids in the 
presence of sulphuric acid. 

Chemical Examination. — Miiller, in the work above 
cited, has described an interesting method for the deter- 
mination of fat in the faeces. The dejecta are treated by 
strong acids and then by an alcoholic solution of potash, 
and finally exhausted by ether; an examination is now 
made to determine the temperature at which the substance 
thus obtained melts. The point of fusion is higher (50° to 
51° 0.-122° to 124° F.) in the normal condition with little 
fat than it is (46° to 48° 0.-114° to 118° F.) in a pathologi- 
cal state when much fat is present. The solidification of 
the substance by cold gives in the same sense even more 
marked results. Miiller also shows how we can extract 
the fat by ether and measure its amount when it exists 
in the stools in the form of neutral fat, of fatty acids, 
or of soaps. But we cannot describe these processes 
here. 

What is the semeiological value of the presence of fat 
in the dejections? In the normal condition, according to 
Miiller, we may find from 7 to 14 grammes of fat ; and this 
amount may be increased to 40 or even 75 grammes in 
pathological conditions, as in icterus. In the healthy in- 
dividual fatty stools may be the result of a diet very rich 
in fats (milk, medicinal oils, etc.). In diseased conditions 
they may be found : 

1 . When the bile necessary for the digestion of fats does 
not pass in sufficient quantity into the intestine. It has 
not been shown, in spite of the generally received opinion 
to the contrary, that there is such a thing as stearrhcea 
from pancreatic insufficiency. 

2. When there is any lesion of the channels through 



32 DISEASES OF THE STOMACH AND INTESTINE. 

which a fat is absorbed (intestinal ulceration, 1 tubercu- 
lous enteritis, amyloid degeneration of the intestine, peri- 
tonitis, or lesions of the mesenteric ganglia). 

3. When the pancreas is injured or the canal of Wirsung 
obliterated, the stools will be found to contain fat in the 
form more especially of combined neutral fat, while in the 
normal condition it is almost always split up into fatty 
acids and into soaps under the influence of the pancreatic 
juice (Muller). 

Starch. — This occurs in the form of minute bodies which 
are colored blue by the following mixture of iodine and 
iodide of potassium : 

Iodine, .1 gramme. 

Iodide of potassium, . . . .2 grammes. 

Water, 300 

Nothnagel regards the appearance of starch corpuscles in 
considerable quantity in the stools as an indication of an 
exaggerated peristaltic action of the bowels ; it is a common 
phenomenon in diarrhoea. The presence of these corpus- 
cles has, however, no special value from the point of view 
of a diagnosis of any very marked lesion of the intestine 
or pancreas (Muller). 

Alimentary Detritus. — There are always incompletely 
digested muscular fibres to be seen in the stools of an in- 
dividual who is on a mixed diet, and there are very many 
of them when the diet is largely composed of meat. The 
quantity of undigested muscular fibres is always increased 
in cases of intestinal catarrh. 

The undigested remains of food to be met with in the 
dejecta are of the most varied sort. In addition to the 
fatty substances, starch granules, and muscular fibres, to 
which we have already referred, there is always a large 
amount of food particles which escape digestion ; among 
these are cellulose, connective-tissue fibres, pieces of ten- 
don, vegetable seeds and fibres, etc. It is hardly neces- 
sary to remark that a vegetable diet will furnish a much 

1 Stadelmann : Deutsches Archiv fur klinische Medicin, Bd. xl., 
p. 372. 



DIAGNOSTIC TECHNIQUE. 33 

more abundant residue than one composed chiefly of nitro- 
genous substances. 

In the diarrhoea of nurslings we often find partially 
digested curds of milk, a sufficient evidence of impaired 
digestion. 

Sometimes, in diarrhceic stools, little transparent masses 
are found which resemble boiled tapioca or frog spawn. 
These were formerly thought to be produced by the mucus 
accumulated in ulcers of the large intestine, but Virchow 
believes them to be of vegetable origin, and Nothnagel 
agrees with him in regarding them as vegetable particles, 
either starch or little pieces of fruit. 

The Bile. — In the normal state the bile does not appear 
as such in the fsecal matters, which, however, owe their 
color to the transformed bile pigments. Bile, as bile, may 
appear in the stools under one of two forms : it may stain 
yellow shreds of mucus, fat, collections of crystals or of 
epithelial cells, and may appear in the form of little clots 
or flocculi of a greenish-yellow color; or it may be inti- 
mately mixed with the liquid stools. 

Nothnagel considers the flocculi (of mucus or other mat- 
ters) colored by bile as an indication of an inflammatory 
lesion of the small intestine, for he says that bile would 
never stain mucus in the large intestine. 

The bile is intimately mixed with liquid fsecal matters 
when there is an intense catarrhal inflammation of the 
small intestine associated with rapid evacuation of its con- 
tents. This is hardly ever seen except in very young chil- 
dren. The bile stains the napkin, and gives the charac- 
teristic reaction in the presence of nitric acid . The stools 
are then green and acid in reaction. This is one of the 
most important varieties of diarrhoea in infants, and should 
not be confounded with the green diarrhoea caused by 
Lesage's bacillus. 

Mucus. — The conditions under which mucus appears in 
the stools have been well studied by Nothnagel. 1 Mucus 

1 " Beitrage zur Physiologie und Pathologie des Darmes, " Berlin, 
1884. 

3 



34 DISEASES OF THE STOMACH AND INTESTINE. 

is normally a constituent of the faeces, but what makes its 
presence abnormal is its quantity and the manner in which 
it is mixed with the other faecal matters ; these points may 
furnish indications concerning the localization of the in- 
flammatory process in the intestine (Nothnagel). 

Mucus may show itself in the stools under one of three 
different aspects : 

1. It may be isolated, unmixed with the other faecal 
matters. 

2. It may form a coating to the formed faecal masses. 

3. It may be more or less intimately mixed with the 
dejecta. 

1. When the mucus is found unmixed with the other 
matters it indicates an inflammatory condition of the rec- 
tum or of the descending colon. It may appear in the 
form of little lumps, of slimy masses, or of membranes, 
ribbons, or tubes (muco-membranous enteritis). These 
products dissolve in large part in alkaline solutions; and 
a precipitate of mucin is obtained by the addition of a 
slight amount of acetic acid. 

2. Mucus forming a coating to solid masses of the de- 
jecta is met with in health as a fine envelope of hyaline 
mucus surrounding the formed faecal cylinders. The pres- 
ence of a thicker opaque, yellowish coating surrounding 
egg-shaped masses of faecal matter is a sign of inflamma- 
tion of the descending colon and rectum. 

3. Mucus mixed with the faeces appears under differ- 
ent aspects according as it is more or less abundant and as 
the mixture is more or less perfect. There may be flocculi 
or little collections of mucus, visible to the naked eye, 
floating in a watery discharge or disseminated among the 
solid matters under the form of masses resembling frog 
spawn or boiled tapioca. This appearance is an indication 
of the existence of inflammation of the colon extending 
into the caecum. We have already said that when these 
masses of mucus are stained by bile we must recognize the 
fact, following Nothnagel, that there is at the same time 
a lesion of the small intestine. 



DIAGNOSTIC TECHNIQUE. 35 

The mucus may be so intimately mixed with the faecal 
matters that it is impossible to recognize it except under 
the microscope; that is an evidence of a lesion limited to 
the caecal region. When at the same time with this inti- 
mate admixture there is also a coating of mucus on the 
formed masses, we may conclude that there is at once a 
lesion of the initial and of the terminal portions of the 
large intestine. The presence of grumous masses resem- 
bling frog spawn or boiled tapioca is not, in Nothnagel's 
opinion, an indication of ulceration of the colon. 

Blood. — This may be present in greater or less amount 
and more or less modified by digestion. 

Red blood accompanying formed faecal masses is an evi- 
dence of a lesion of the rectum or anus, most commonly 
hemorrhoids. Red blood accompanying liquid stools may 
come from higher up in the bowel, even from the small 
intestine, as is seen more especially in typhoid fever when 
the hemorrhage has been abundant. Nothnagel calls at- 
tention to a point of some importance, viz., that when 
small quantities of blood are found in the stools of a pa- 
tient with typhoid fever we should be on the lookout for a 
profuse hemorrhage within a short time ; sometimes these 
little premonitory hemorrhages can be detected only on 
microscopical examination. 

When the blood comes from the stomach or duodenum 
it is often of a black color like tar, or soot beaten up in 
water. Usually the blood is easily recognized in this form 
by simple inspection, but sometimes it must be more care- 
fully examined before its true character can be deter- 
mined. The blood corpuscles may be looked for under the 
microscope, where they will be seen more or less deformed, 
or a search may be made for haemin crystals. 

The following procedure may be used for the detection 
of haemincrystals : the liquid to be examined is evapo- 
rated carefully without too much heat in a watch-glass held 
in the hand over an alcohol lamp. A piece of the desic- 
cated product the size of a millet-seed is put upon a glass 
slide and to this a small grain of sea-salt, together with 



36 DISEASES OF THE STOMACH AND INTESTINE. 

two drops of acetic acid, is added; the acetic acid is evap- 
orated gently over the lamp; a little more is added and 
again evaporated; a few drops of water are then added, a 
cover glass is put over it and it is examined under the mi- 
croscope in order to discover the characteristic crystals of 
hsemin. 

The blood may also be examined by means of tincture 
of guaiac. To a small quantity of the liquid to be exam- 
ined about one cubic centimetre of fresh tincture of guaiac 
and one cubic centimetre of the following mixture are 
added : 

Crystallized acetic acid, ... 2 grammes. 

Distilled water, 1 gramme. 

Essence of turpentine, 

Rectified alcohol, .... iia 100 grammes. 

The mixture is then thoroughly shaken. If there is any 
blood, a blue color is produced. 

Spectroscopic examination is, as is well known, the most 
sensitive means of demonstrating the presence of blood. 

Examination of blood present in the vomited matters is 
made in exactly the same way. 

Pus. — This is sometimes abundant enough to be recog- 
nized by the naked eye, but it is rarety found in consider- 
able amounts except when some purulent collection has 
opened into the colon or the rectum. 

In cases of lesions of the rectum, of the upper part of 
the colon, or of the sigmoid flexure we may find small 
quantities of pus recognizable by the naked eye and under 
the microscope. This is not the case when ulcerations are 
present higher up in the bowel, so that, although the pres- 
ence of pus is a symptom of intestinal ulceration, it is not 
always safe to count upon it in the diagnosis of this condi- 
tion. It is probable that the pus is destroyed en route, is 
either dispersed or digested. Hemorrhage is therefore in 
this sense a sign of much greater importance. 

There does not seem to be any simple purulent catarrh 
of the intestinal mucous membrane, like bronchial catarrh 
for example ; Nothnagel has shown by numerous examina- 



DIAGNOSTIC TECHNIQUE. 37 

tions that there is no purulent secretion without ulceration 
in the intestine. 

We shall have to content ourselves here with these ele- 
mentary remarks on examination of the faeces. We can- 
not enter into a study of intestinal parasites (worms, pro- 
tozoa, bacilli), as that would demand too long and minute 
a consideration. 



PART II. 

GENERAL CONSIDERATIONS ON DIET. 

Before taking up in succession the different clinical 
forms of dyspepsia, we think it would be well to make a 
short study of the diet appropriate for this condition. We 
shall thus be able to dispose of a few preliminary details 
for which it would be difficult to find a place in the chap- 
ters on special diseases, and on the other hand we shall be 
able to avoid needless repetitions. 

Physiologists have arrived at very concordant results in 
regard to the quantity of alimentary substances of the three 
kinds which is necessary to the maintenance of life in an 
adult man. According to the mean of the analyses made 
by different observers, 1 a man in repose requires each day 
100 grammes of albumen, 45.4 of fats, and 373 of carbo- 
hydrates. For a man who is actively exercising the fig- 
ures should be a little higher than these. Voit estimates 
the necessary amount as follows : albumen, 1 1 8 grammes ; 
fats, 50; carbohydrates, 500. 

These substances are not found in food in a state of 
purity, but are mixed with each other and also with other 
substances which are not capable of being digested at all. 
Furthermore a certain proportion of the digestible matters 
pass through the alimentary canal without having been 
acted upon b} T the digestive juices. The quantity of food 
taken ought, therefore, to be appreciably greater than the 
amount of pure nitrogenous or carbonaceous substances 
necessary for the maintenance of the organism. 

A. Gautier has drawn up an average diet table for an 

inhabitant of Paris, using as a foundation the statistics of 

1 A. Gautier, "Coursde Chimie, " vol. iii., p. 796. 
38 



GENERAL CONSIDERATIONS ON DIET. 



39 



the amount of food -stuffs passing through the municipal 
custom-house during a period of several years. We re- 
produce this table here because it gives at the same time 
the average quantities of albuminoids, fats, and carbo- 
hydrates contained in the different varieties of alimentary 
substances. 1 It will be remarked that the results thus ob- 
tained are very similar to those that physiologists have 
arrived at by very different processes. 



Nature of the Foods. 



Bread 

Meat (fish, game, fowl 
butcher's meat 

Vegetables (fruit, 98 
fresh vegetables, 100 
potatoes, 100) 

Eggs 

Milk 

Cheese. .'.- 

Butter 

Sugar 

Salt 

Wine (about half a litre) 

Total 



Amount per 
Day per Head. 


Albu- 
minoids. 


Fats. 


410 


36.9 


4.8 


266 


53.0' 


41.0 


298 


12.5 


1.6 


25 


3.6 


3.5 


150 


7.1 


6.0 


6 


2.0 


1.2 


25 


0.3 


20.0 


40 


0.0 


trace 


18 


0.0 


0.0 


500 


trace 


trace 




115.4 


48.1 1 



Carbo- 
hydrates. 



184.5 
3.0 



60.1 

trace 

6.0 

trace 

0.0 

40.0 

0.0 

40.0 



333.6 



Healthy individuals have no great difficulty in regu- 
lating the amount of food to their needs ; it is only neces- 
sary for them to be able to procure a sufficient variety. It 
is not the same in case of disease, when digestion is not 
normally accomplished. It is then necessary to take food 
only in sufficient amount, not too much, and in such shape 
as will permit of its digestion under the unfavorable con- 
ditions in which the gastro-intestinal tube is performing 
its functions. This adaptation of food to morbid indica- 
tions constitutes diet, which occupies an important posi- 
tion, the first indeed, in the treatment of dyspeptic condi- 
tions. 

Diet. — Each of the clinical forms of dyspepsia, primary 

1 The same work contains a table showing the chemical composi- 
tion, richness in water, salts, albuminoids, etc. , of the differeat 
foods. 



40 DISEASES OF THE STOMACH AND INTESTINE. 

or secondary, presents special elementary indications to 
which we shall refer in detail later. Here, we would give 
only certain general indications as to what ought to be the 
diet in the treatment of dyspepsia, and as to the condi- 
tions which the different diet tables are expected to fulfil 
in the management of diseases of the stomach. 

The first condition of a diet list is that the three orders 
of alimentary substances should be represented there in 
suitable proportion, for they cannot be substituted one for 
the other, and the insufficiency or absence of one of them 
would produce actual starvation. 

Various authors have drawn up tables showing the pro- 
portions in different foods of albumen, fats, and carbohy- 
drates. Dujardin-Beaumetz in particular has inserted in 
his book on the treatment of diseases of the stomach a 
colored table which presents in a way very striking to the 
eye the relative richness of different substances in nitro- 
gen, carbon, fat, and water. By a reference to this it 
will always be easy to determine whether the diet that 
one has ordered is sufficient and suitably proportioned. 
Space will hardly permit us to reproduce tables of this 
kind here. 

The great difficulty is especially to prescribe food which 
may be utilized without causing suffering in different 
forms of dyspepsia ; to prescribe food which demands of 
the digestive tube a minimum of work, and which leaves 
the least possible injurious residue. 

This is the difficult problem of the digestibility of foods, 
and of their digestibility applied to different cases. We 
shall consider for the moment this digestibility only in a 
general way. It must be owned that in this respect cer- 
tain and precise data are wanting. The classification of 
foods according to the sensations felt during their diges- 
tion must be very indefinite, varying according to the in- 
dividual, and consequently can have no general applica- 
tion. Observations made on dogs killed while digesting 
(Leven), on individuals with gastric fistulse (Beaumont, 
C. Richet), studies made on persons who can vomit at will 



GENERAL CONSIDERATIONS ON DIET. 41 

(Gosse), have only a limited value; they are particular 
cases, the expression of certain individualities, that is all. 
Besides, these experiments have given hardly any informa- 
tion except as to the greater or less duration of time during 
which foods remain in the stomach. Long and careful 
chemical examinations would be necessary to give us any- 
thing certain in this respect as regards not only the healthy 
individual but also the sick. It is the latter in whom the 
physician is especially interested. 

In the mean while writers have contented themselves 
with the table of digestibility drawn up by Leube. This 
experimenter emptied the stomach by a tube from five to 
seven hours after a meal, and took account, not of the chem- 
ical state, the most important, but of the physical condi- 
tion of the foods. He has in this way drawn up the fol- 
lowing list, which we give as a matter of instruction for 
what it is worth. The different foods are there arranged 
in the decreasing order of their digestibility. 

First Dietary. 

Bouillon. Biscuit. 

Meat solution (Leube-Ro- English cakes (Albert bis- 

senthal). 1 cuit). 

Milk. Water. 

Raw eggs. Natural carbonated waters. 

Second Dietary. 

Boiled calves' brain. Boiled squab. 

Sweetbreads, boiled. Tapioca soup. 

Boiled spring chicken, with- CEufs a la neige. 8 
out the skin. 

1 The Leube -Rosenthal meat solution is prepared in the following 
way : finely minced beef is cooked in a Pa pin digester for twenty- 
four to thirty-six hours, hydrochloric acid having been added. This 
acid is saturated before the food is given. 

2 White of eggs beaten up into a light froth, then cooked in boil- 
ing milk and sweetened. 



42 DISEASES OF THE STOMACH AXT) INTESTINE. 

Third Dietary. 
Raw beef, finely minced. Mashed potatoes. 

Raw ham, finely minced. Stale white bread. 

Rare beefsteak. Tea and coffee, with milk. 

Tenderloin of beef (reduced 
to a pulp). 

Fourth Dietary. 

Roast chicken. Boiled rice. 

Roast squab. Spinach finely minced. 

Roast venison or partridge. Asparagus. 

Cold roast beef. Steamed apples. 

Roast veal. White or red wine, well di- 

Boiled salmon. luted. 
Maccaroni. 

Certain of the indications given by Leube may assuredly 
be utilized; for example, the physician may find sugges- 
tions there for a diet list for convalescents or even for cer- 
tain dyspeptics. In Germany cold joints are often advised 
in cases of dyspepsia; indeed, one might say that they 
actually have " cold-roast cures. " 

We shall content ourselves here with giving certain 
general indications applicable, as it were, to all cases of 
dyspepsia in common. There are a certain number of 
conditions, as regards both the nature and external form 
of the food, which are essential before the latter can be ad- 
mitted into the dietary of dyspeptics. 

The food should be: 1, finely divided; 2, in sufficient 
quantity, but not in excess, and varied in such a way as 
to furnish albuminoids, carbohydrates, and fat in sufficient 
amount and due proportion; 3, as far as possible rendered 
unirritating to the mucous membrane of the stomach and 
intestine; -1, and finally should contain toxic products in 
minimum amount. We will inquire into the reasons for 
these different essentials and the means of realizing them. 

1. The fine division of food has two principal advan- 
tages: it brings the nutritive material in most intimate 



GENERAL CONSIDERATIONS ON DIET. 43 

contact with the digestive juices, and it also renders the 
passage of the alimentary substances through the digestive 
tube more easy. Under these conditions the mass of in- 
gested material need not be so great, since it is better elab- 
orated and its utility to the organism is proportionately 
greater. 

2. The three varieties of substances, united in suitable 
proportions, must be in sufficient but not too great quan- 
tity. Absolute insufficiency or a relative insufficiency of 
one of the essential ingredients would necessarily reduce 
nutrition below the normal. Sometimes the problem is 
more difficult, as when we have to devise a means of in- 
troducing into the circulation some substance which the 
alimentary canal digests with difficulty — for example, car- 
bohydrates when there is hyperacidity, or albuminates 
when there is a deficient secretion of hydrochloric acid. 
In most cases of dyspepsia, always, in fact, the overloading 
of the digestive tubes should be avoided, for this is, gener- 
ally speaking, one cause of stasis and of abnormal fermen- 
tation, with all their evil consequences. It is for this rea- 
son that we often are obliged to diminish the quantity of, if 
not to suppress entirely, those aliments which contain too 
great an amount of indigestible waste. In this category 
belong especially vegetables and green fruits very rich in 
cellulose. These substances, although they have in cer- 
tain cases the advantage of being laxative, more often 
possess the inconvenient property of affording little nour- 
ishment and at the same time being bulky. 

3. All substances which are needlessly exciting or irri- 
tating to the stomach and intestine ought to be avoided. 
Spices, condiments, and strong liquors are the best exam- 
ples of this class of irritants. The use of condiments 
ought to be restricted to a minimum in the different forms 
of dyspepsia, salt alone being permitted. Indeed in all 
cases of dyspepsia it should be our aim to avoid the pro- 
duction of gastritis if it does not already exist, and to 
moderate its severity or even bring about its cure if it is 
already present. The culinary preparation of food ought, 



44 DISEASES OF THE STOMACH AXD INTESTINE 

therefore, to be simple, while at the same time regard 
should be had for variety and palatableness. Seurre has 
given, in his " Etude Pratique sur les Maladies de l'Es- 
tomac" (1885), some practical advice in this respect which 
might be followed with profit. 

4. The poisonous products which arise during fermenta- 
tion of food in the stomach may be injurious locally or at 
a distance; we should endeavor, therefore, to prevent their 
introduction, or restrict as far as possible their production 
in the stomach and intestine. Putrefaction develops many 
of these products, and we ought therefore to avoid game 
or meat which is too high, strong cheese, and the like. 
Other substances which are still wholesome undergo fer- 
mentation too readil}^ and therefore furnish material for 
toxic or irritating products. Among these are sugar and 
fatty substances. 

The first place, leaving out of consideration milk and its 
special preparations, of which we shall speak further on, 
belongs then to meat, eggs, fish, preparations of farina, 
and thick soups; these are the only varieties of food which 
remain after the above-mentioned eliminations have been 
successively made. 

Meat. — In order to conform to the desiderata previously 
enumerated, meat must not be too fat and should be sim- 
ply prepared, fresh, and very finely divided; it may be 
cooked or raw. We shall speak below of meat powder, 
which deserves a special study by reason of the peculiar 
conditions of its elimination. 

Raw meat may be especially useful in cases of convales- 
cence, of anaemia, of chlorosis, of neurasthenia where there 
is much debility, and of excessive secretion of hydrochloric 
acid. Mutton or horse-flesh is preferable to beef, since it 
does not expose the patient to the danger of tape- worm. 
This may be prepared in several ways: it may be passed 
through a hashing machine of the kind made in America, 
which has the disadvantage, however, of drying the meat, 
or it may be minced or scraped with a knife. When it is 
desired to mince it very fine it should first be cut up in 



GENERAL CONSIDERATIONS ON DIET. 45 

larger pieces by the butcher, all the white parts, such as 
fat, tendons, vessels, etc., being removed, and then hashed 
up fine at home. It should then be picked over again to 
remove all the white parts that may still remain. To 
complete the operation it may be worked up in a mortar 
or passed through a sieve. 

Scraping with a knife is even preferable to mincing. A 
piece of a leg of mutton is placed on a board and scraped 
with a dull knife; the meat is turned over from time to 
time and the pulp is collected in a bowl. This process, 
when well done, demands much care and attention. When 
a mechanical pulper is used, which, as we have said, has 
a tendency to dry the meat, the latter should be cut into 
small pieces and freed from all fat, tendons, etc., before 
being put into the machine. This removal of the white 
parts should always be attended to so as to avoid introduc- 
ing into the stomach any substances which are difficult of 
digestion and which would tax the organ uselessly. 

Pulped raw meat may be taken in different ways: it 
may be stirred into bouillon, which must not be too hot, 
for fear of coagulating the meat and hardening its fibre, 
or it may be given in tapioca or mixed with purees. In 
the case of children it may be easily given by mixing it 
with preserves, but for most dyspeptics such an amount 
of sugar would be apt to cause trouble. It may, as Seurre 
advises, be lightly cooked on a gridiron and moderately 
seasoned. It may also be fried with a little butter, a mode 
of preparation that I often employ for convalescents from 
typhoid fever. 

Cooked Meat. — We may use beef, veal, lean pork, mut- 
ton, and chicken, and the different kinds of meat may be 
either boiled, roasted, or broiled. We may also reduce 
cooked meat to pulp and thus vary its administration. The 
meat may be given alone, lightly seasoned, or in thick 
soups, or with scrambled eggs. Ham may be prepared in 
the same way, raw or cooked, but especially when raw it 
mixes very well with eggs. A cook who possesses a little 
ingenuity may provide a great variety of ways in which 



46 DISEASES OF THE STOMACH AND INTESTINE. 

to give nitrogenous food, while using only pulped meat. 
The latter has a very great advantage over ordinary meat, 
since simple mastication can never divide meat sufficiently. 
Pulped meat may also be combined with the aliments 
which go to make up what we call a vegetable diet, of 
which we shall speak further on. It will be seen that in 
moderate cases of dyspepsia it is easy, with milk as an 
adjuvant, to prepare quite varied bills of fare which will 
fulfil the general conditions that we have enumerated 
above. 

Meat Solutions, Peptones. — We have described above 
the preparation of meat solution by the Leube-Rosenthal 
method. There are many other analogous formulae which 
we do not think worth while to reproduce here. 

Prolonged boiling in a closed vessel will dissolve out a 
certain quantity of gelatin which, according to some au- 
thors, is utilizablo as albumen. Without denying that 
these concentrated gelatinous soups may have their place, 
they certainly ought to be used only temporarily when 
better preparations are not acceptable to the patient, or 
when we desire to vary a monotonous bill of fare. It is 
more useful during convalescence than in cases of true 
dyspepsia. 

Meat juices have only a ver} r feeble nutritive value, and 
we should not deceive ourselves on this point. 

Peptones are of no use whatsoever. Their composition 
is too variable and too complex, and it has never been 
shown, furthermore, that artificially prepared peptones are 
susceptible of absorption and assimilation. We are far 
from having solved all the mysteries of the chemistry of 
digestion and from being able to obtain in a test-tube 
chemical actions which are equivalent to those that take 
place in the digestive canal under normal conditions. 

Extracts of meat are also without any alimentary value; 
they are useful only to make soup and, like bouillon, serve 
only as a peptogenous aliment, if we admit the well-known 
theory of Schiff and Herzen. According to these authors 
bouillon, little nutritive as it is in itself, is of value in the 



GENERAL CONSIDERATIONS ON DIET. 



47 



way of recharging the glands which have been exhausted 
of propepsin; in other words, it is peptogenous. Here we 
see the possible utility of taking soup at the beginning 
of a repast, but it would be more logical, if this theory is 
correct, to take our bouillon a little while before the 
meal. 

Milk and its Derivatives. — Milk is the food which 
should serve as the exclusive nourishment of the mam- 
mif er during the first period of its life ; it is therefore a 
complete food, the composition of which, however, varies 
considerably according to the species. 

What is the quantity of milk necessary for the support 
of an adult man? This question is easily answered by 
comparing the figures of a diet of maintenance with those 
furnished by an analysis of milk. The normal ration of 
maintenance ought to contain, taking the extremes indi- 
cated by various writers : 



Albuminoids, . 
Fatty substances, 
Carbohydrates, 



100 to 120 grammes. 
40 to 55 
375 to 500 



On the other hand, the different varieties of milk have 
on the average and in round figures, according to the table 
given by Gautier, 1 the following composition, indicated in 
grammes per litre : 



Albuminoids . . . 
Fatty substances 
Milk sugar 



Woman. 


Cow. 


Ass. 


20 


50 


20 


45 


40 


15 


70 


55 


58 



Goat. 

87 
85 
27 



A very simple calculation will give in round numbers 
the quantity needed of these different kinds of milk to fur- 
nish the proper amount of each of the substances entering 
into the composition of a normal diet. The following table 
gives these amounts expressed in litres : 



" Cours de Chimie, " vol. iii., p. 711. 



48 



DISEASES OF THE STOMACH AXD IXTESTIXE. 





Woman. 


Cow. 


Ass. 


Goat. 


Albuminoids 


5 to 6 

1.50 
5 to 6 


2 to 3 
1.50 
6 to 7 


5 to 6 
3 

6 to 7 


1 50 


Fattv substances 


0.75 


Milk sugar 


16.00 



If we order four litres a day of cow's milk, an amount 
quite frequently given, we obtain : 



Albuminoid substances, 
Fatty substances, 
Milk sugar, 



200 grammes. 

1(50 

220 



There is in this a slight excess of nitrogenous substances, 
a considerable excess of fats, and a notable deficiency of 
carbohydrates. It is pre-eminently, as Germain See has 
remarked, a fatty diet. This excess of fatty substances 
explains the fact that the stools are white or yellowish, 
certainly very rich in butter, during the continuance of a 
milk diet. It is therefore advisable to use partially skimmed 
milk. With 5 litres of milk from which about two-thirds 
of the cream has been removed, there would still be an ex- 
cess of fat and a deficiency in carbohydrates. A milk diet 
cannot therefore be continued for a long period of time in 
an adult, and especially in an adult who is working, be- 
cause of the enormous quantity of liquid that he is obliged 
to take. It is possible, it is true, that fatty substances 
may partially replace the carbohydrates in the functions of 
oxidation and the production of energy, but in order to 
obtain that result they must be digested and absorbed, and 
we have no sufficient data in relation to their absorption 
and utilization in the economy. 

A milk diet, notwithstanding the richness of this sub- 
stance in fat, is a lowering diet when emplo} T ed alone, but 
a fattening diet when the milk is given in addition to other 
substances. It is easy to understand why. 

Every-day experience teaches us that milk is an excellent 
curative agent in a large number of cases of dyspepsia. 
We must now endeavor to understand the nature of this 



GENERAL CONSIDERATIONS ON DIET. 49 

beneficial action in order that we may know clearly what 
we can and should demand of milk in these cases. 

When once it has entered the stomach the milk coagu- 
lates. This coagulation, which was formerly thought to 
be due to the acidity of the gastric juice, is perhaps due 
rather to the presence of a special ferment which has been 
studied by Hammarsten. This ferment is called rennet 
(German, Lab; French, presure). This rennet coagu- 
lates milk in an alkaline medium. According to the re- 
searches of many authors the rennet would appear to be 
the last substance which disappears when the mucous 
membrane of the stomach is progressively destroyed by 
gastritis. It is this fact, perhaps, which explains the good 
effects of a milk diet in cancer of the stomach and in cer- 
tain chronic destructive forms of gastritis. As this coagu- 
lation occurs in an alkaline medium we can also understand 
the good effects produced from this point of view by the 
administration of alkaline substances in rather large doses, 
especially when there is a tendency to hyperacidity. 

Many attribute a specially happy action to lime salts in 
the digestion of milk. According to Hammarsten the 
presence of soluble lime salts is necessary in order that co- 
agulation of casein may take place. Under such circum- 
stances, according to Arthus and Pages, * a special chemical 
reaction occurs, viz., formation of an earthy albuminate. 
The gastric rennet acts in an alkaline medium ; now it is 
probable that the milk introduced into the stomach is only 
very feebly acid and that it even remains alkaline there for 
a considerable period when it has been previously alkalin- 
ized. The coagulation of the casein takes place, therefore, 
without the intervention of lactic acid, which is a great 
advantage. 

It is very probable that in the normal condition the gas- 
tric digestion of milk is limited almost exclusively to this 
precipitation of the casein, and that a very small part only 
is peptonized in the stomach. Writers are far from being 
in accord as to the time that milk remains in the stomach ; 

1 Quoted by Hayem, loc. cii., p. 316. 

4 



50 DISEASES OF THE STOMACH AND INTESTINE. 

this time must vary greatly in individual cases, but it 
would appear that it is in general less prolonged than in 
the case of other alimentary substances. Leube, as we 
have seen, ranks milk ver}- high from the point of view of 
its digestibility, that is to say, of the rapidity of its disap- 
pearance from the stomach. 

The coagulum produced by the precipitation of casein 
varies in appearance in individual cases and also accord- 
ing to the kind of milk that is ingested. The curds of 
cow's milk are alwa} T s larger than those of human milk. 
It is possible, also, that the coagula are larger in d} T spep- 
tics in whom the motility of the stomach is weakened. 
Milk tends to cause the disappearance of free hydrochloric 
acid, which doubtless combines with the casein; it acts, 
therefore, somewhat like an alkali. To this fact, in part, 
are due the good effects seen in the case of round ulcer and 
hyperacidity. It also acts in a comparatively slight de- 
gree as a stimulant to the gastric mucous membrane, as 
might a priori be supposed, the result of which is that 
there is a less abundant secretion of hydrochloric acid 
(Hayem) . 

It is true that the lactose which it contains may ferment 
in the stomach and give rise to the formation of lactic 
acid, the presence of which is easily determined by quali- 
tative tests. This undesirable effect may be moderated or 
even prevented by the simultaneous administration of an 
alkali, and this should always be done when there is a 
tendency to hypersecretion of hydrochloric acid and to 
stasis of the gastric contents. 

We have seen that a full milk diet has serious disadvan- 
tages; in order to supply nutritive substances in sufficient 
quantity we must give an excessive amount of liquid, and 
this may lead to dilatation of the stomach (Debove). And 
when we give only three or four litres of cow's milk there 
is a notable deficiency of carbohydrates. A milk diet, in- 
deed, ought to be only a temporary affair, and we should, 
as far and as soon as we can, add other articles of food 
and especially starchy matters. We may also add sugar 



GENERAL CONSIDERATIONS ON DIET. 51 

of milk in order to make up the deficiency in carbohydrates ; 
we have done this with advantage in cases of hyperacid- 
ity, and it is a measure worth trying. 

Foods Derived from Milk. — Milk is the basis of a cer- 
tain number of alimentary products, especially designed 
for the treatment of gastro-intestinal affections. The prin- 
cipal preparations of this kind met with in commerce are 
the following : sterilized mlik, condensed milk, milk pow- 
der, peptonized milk with diastase, milk to which pan- 
creatin has been added, kumyss, kephir. Sterilized milk 
has seemed to be really useful in the treatment of certain 
forms of diarrhoea, especially in infants (Sevestre, Com by, 
Hay em). There is no reason why it should not also be 
tried in the treatment of diarrhoea in adults and especially 
in the treatment of certain forms of chronic diarrhoea. It 
would be logical to employ it also in cases of dilatation of 
the stomach with permanent stasis, excessive fermenta- 
tion, etc. 

Condensed milk and milk powder would find a rational 
application in the same cases as meat powder, but they are 
much inferior to the latter. 

Kuymss and kephir are forms of fermented milk the 
use of which has been greatly vaunted, especially in the 
treatment of tuberculosis, and they have also, kephir espe- 
cially, been much employed in dyspepsia. Hayem, who 
is a great advocate of this preparation, has made an in- 
teresting study of it, of which the following is a resume : 
Kephir is milk fermented by means of a special yeast 
which is much used by the natives of the Caucasus ; it is 
a mixture of ordinary yeast and a special bacillus. The 
kephir made in Paris, according to an analysis made by 
Winter, contains very little alcohol, a large amount of 
carbonic acid, from 3 to 6 parts per 1,000 of lactic 
acid, a small quantity of sugar of milk, and from 7 to 8 
parts per 1,000 of albumin or of syntonin (acid albu- 
min). Its acidity is due chiefly to the presence of free 
lactic acid, and probably also to the presence of this acid 
in nitrogenous combination. 



O'i DISEASES OE THE STOMACH AND INTESTINE. 

Kephir has been employed with success by Lepine, 
Weiss, and O. Wyss, in simple ulcer of the stomach; by 
Dujardin-Beaumetz in alcoholic gastritis; by Stern and 
Lowenstein in gastric catarrh ; Hay em regards it as the 
best remedy for pronounced hypopepsia or apepsia. It is 
regarded as a stimulant of the gastric secretion and motil- 
ity, and it is therefore of little service when the greater 
part of the mucous membrane of the stomach has been de- 
stroyed. Kephir is especially indicated in chronic enteritis 
and in diarrhoea; its good effects in the latter condition 
are attributable to the large proportion of lactic acid which 
it contains (Hay em). It has always a tendency, when 
taken continuously, to induce constipation. It should be 
given in small quantities at the beginning, not more than 
two bottles, part of which is to be taken with meals and 
the remainder between meals. When three bottles a day 
are taken the patient should avoid other fluids. The dose 
may be gradually increased up to six pints or more in the 
twenty-four hours. Certain patients cannot tolerate it, 
and it is contra-indicated in cases of pronounced dilata- 
tion with stasis. 

One may readily understand from its composition that 
kephir is an excitant of the stomach ; its rather marked 
acidity and its richness in lactic acid show that one 
ought not to judge merely from the acidity of the gas- 
tric juice as to the intensity and the gravity of dyspep- 
sia. The great question, the principal one in fact, is to 
know how and with what rapidity the stomach empties 
itself of its contents. 

Food Powders. — M. Debove was the first to make use 
of meat powder in the treatment of pulmonary tuberculo- 
sis. The good results which he obtained by feeding with 
the tube, even when there were signs of marked indiges- 
tion present, led to the employment of meat and other 
food powders in cases of primary dyspepsia, and the re- 
sults have been equally good in these cases as in the sec- 
ondary forms. Meat powder, indeed, combines in itself 
all the requisites of a nitrogenous food for dyspeptics. The 



GENERAL CONSIDERATIONS ON DIET. 53 

meat is finely divided and freed from all waste matter that 
will resist digestion. It contains a great deal of nutritive 
material in small volume, representing almost four times 
its weight of meat. 1 

There are several kinds of meat powder in the market, 
but they all present more or less the same disadvantages ; 
they have a very disagreeable odor, which makes their di- 
rect ingestion difficult, and their prolonged administration 
almost impossible in spite of all attempts to disguise this 
odor. Meat powder should therefore be given usually by 
the oesophageal tube. Docile patients readily submit 
themselves to this manoeuvre, which may, with a little 
practice, be executed very rapidly ; and they seldom have 
to regret having done so, for meat powder produces ex- 
cellent results in almost all forms of dyspepsia. 2 As a 
rule a certain amount of an alkali, having relation to the 
chemical type of the dyspepsia under treatment, is added. 

The researches which we have made in company with 
Remond, in Debove's laboratory at the Hopital Andral, 
have made clear to our comprehension the mechanism of 
this beneficial action. The prepared meat powder exerts 
an extremely feeble irritant action upon the gastric mucous 
membrane ; in some individuals the amount of hydrochloric 
acid excreted in a given time is much less with meat pow- 
der than with bread, and when alkalies have been added 
this small quantity of acid is easily saturated, so that it 
would appear that gastric digestion is almost completely 
suppressed. This has a tendency again to reduce the ex- 
citation of the mucous membrane of the stomach. The 
administration of milk habitually combined with meat 
powder furnishes a diet that procures the greatest amount 
of repose for the stomach ; this effect is the opposite to that 
attributed to kephir. 

Meat powder then is digested especially in the intestine 

1 Yron : " On Meat Powders, " Bulletin de Therapeutique, January 
15th, 1884. 

2 G. M. Debove and Remond (of Metz) : " Lavage of the Stomach, " 
Bibliotheque Medicale, p. 191 et seq. 



54 DISEASES OF THE STOMACH AND INTESTINE. 

by means of the pancreatic juice, and it is well digested, as 
the increased weight of the patient and the greater excre- 
tion of urea bear testimony. 

When it is to be given by the tube the meat powder 
ought to be beaten up with water, milk, or bouillon into a 
paste thin enough to pass readily through the tube without 
clogging it. To accomplish this we must proceed slowly 
at first, rubbing up the powder with the fluid in a bowl, 
breaking up the little lumps with a spoon ; as soon as all 
the powder has been thoroughly moistened the rest of the 
fluid may be poured on more rapidly. 

The following is the method of Dujardin-Beaumetz for 
making fresh meat powder: Take raw meat pulp, or that 
made from meat cooked in a water bath, and dry it; when 
it is thoroughly dried and yellow, pass it twice through a 
coffee-mill, the machine being screwed up the second time 
so as to grind veiw fine. Powder thus made has a pleasant 
odor of roast meat and an agreeable taste. Milk powder 
has been prepared in the same way by Debove, but the re- 
sults are not as good as those obtained with powder of meat. 

This same principle of the minute division of alimentary 
products has been applied to the starchy foods. Farinas 
of all kinds — peas, lentils, beans, rice, etc. — are on the 
market. Many German physicians regard with great 
favor meal made of oats and barley. These various farinas 
are often very serviceable, but they should of course be 
cooked. They are useful in making thick soups or purees, 
and serve to supply the deficiency in carbohydrates which 
exists when meat powder and milk are given exclusively. 
They may be introduced into the stomach through the 
tube at the same time as the meat powder, but this mode 
of administration is less often necessary for the farinas 
than it is for meat powders. 

The famous " revalesciere, " a preparation in vogue in 
France, owes its success to the application of this princi- 
ple ; and it is said also to owe it furthermore to the fact 
that it is made of lentils and other starchy grains in pro- 
cess of germination and therefore contains diastase, which 



GENEKAL CONSIDERATIONS OX DIET. 55 

diastase favors the transformation of amylaceous sub- 
stances into glucose ; advantage is thus taken of a sort of 
digestion due to germination. The attempt has been made 
to take advantage of the same fact in the employment of 
malt, a product of germinated barley. The use of these 
farinas made from germinating grain is sometimes very 
advantageous, but they must be given with caution be- 
cause of the readiness with which they undergo acid fer- 
mentation in the stomach when there is a certain degree 
of alimentary stasis. 

German physicians speak highly of soups made by pro- 
longed boiling of barley, oats, or rice. The glutinous sub- 
stance which is thus formed is thought to have the prop- 
erty of furnishing a sort of protecting covering to the 
mucous membrane of the stomach. This is the theory, 
but whether it is correct or not the practical results are 
said to be excellent. These preparations are, however, 
contra-indicated when there are acid eructations, pyrosis, 
or painful gastric spasms (Boas) . 1 

Vegetarian Dietary. — The following are the rules laid 
down by Dujardin-Beaumetz : 2 " The patient must live 
exclusively on eggs, starchy foods, green vegetables, and 
fruits. 

"A. Eggs under all forms, boiled, scrambled, omelettes, 
etc. 

" B. The starchy foods must be in the form of purees, 
as mashed potatoes, beans and lentils, racahout, farina 
with milk, chocolate, 'revalesciere,' farina, rice, barley, 
maize, and oatmeal gruel, bread soup, rice in all forms, 
various food pastes, noodles, and maccaroni. 

"C. All the green vegetables are allowable; purees of 
carrots, turnips, etc., cooked salads, spinach, etc. 

"D. The fruits should be stewed; pastry is permitted. 

" Bread is also allowed. As a drink beer may be taken 
or extract of malt diluted with Alet water or with milk. 
Undiluted wine and liquors are forbidden." 

1 "Diat und Wegweiser fur Magenkranke." 

2 " Traitement des Maladies de l'Estomac," p. 140. 



50 DISEASES OF THE STOMACH AND INTESTINE. 

The so-called vegetarian diet is therefore a rather varied 
one; it is a mixed diet from which meat is excluded. If 
care is taken to give only vegetables which are cooked and 
mashed or in thick soup, and to proportion the different 
elements according to the needs of the case, this regime 
may be productive of excellent results in certain neuras- 
thenics who have been living on a too rich or too nitro- 
genous diet, and in nervous dyspeptics who are troubled 
with obstinate constipation. Baredet ' says it is very use- 
ful in cases of hyperchlorhydria. In the cases upon which 
he based his observations there was doubtless a very slight 
degree of hyperacidity not due to hypersecretion and un- 
accompanied by permanent stasis, for in such a condition 
starches are digested with difficulty by the stomach be- 
cause of the excessive amount of hydrochloric acid pres- 
ent; they simply remain there and swell up. When the 
green vegetables remain in the gastric fluids they increase 
still more the irritant action of the latter upon the mucous 
membrane of the stomach. In our own experience the 
vegetarian diet is very badly borne in cases of continued 
hypersecretion of hydrochloric acid with stagnation of the 
contents of the stomach. This diet is indicated rather in 
cases of organic hyperacidity without pronounced gastric 
stasis, but even then it ought to be begun gradually; in 
proportion as improvement takes place starches in the 
form of gruel or thick soups, and finally green vegetables, 
may be added to a diet of milk and eggs as a basis. On 
the other hand, starches and green vegetables may form 
the main part of the diet in patients in whom intestinal 
atony and constipation are the predominant symptoms. 

Various Cures. — The grape cure is practised especially 
in Germany and Switzerland. It is also employed in a 
few places in France, but its application might be greatly 
extended. The grapes should be eaten from the vine; and 
perhaps the climato-therapeutic element, the "country 
cure," is more important than the grape cure itself. The 
grapes should be fully ripe and should not have too thick 
1 Societe de Therapeutique, November, 1892. 



GENERAL CONSIDERATIONS ON DIET. 57 

skins ; in any case the latter should be rejected as well as 
the seeds. Patients begin by taking one or two pounds a 
day, increasing the amount gradually to ten or twelve 
pounds. At the beginning the patients usually suffer 
from symptoms of over-repletion of the stomach and in- 
testines, from indigestion and slight purgation. During 
the cure a light diet is prescribed. The grape cure seems 
to be adapted especially for plethoric individuals who have 
a tendency to obesity and at the same time suffer from 
constipation. 

The whey cure resembles in general the grape cure. 
Whey, like grape juice, contains sugar, albuminoid sub- 
stances, and salts, but in much larger quantities. It is 
quite often used in Switzerland and Germany. It pro- 
duces in general about the same effects, and consequently 
the indications for its employment are the same as those 
for that of the grape cure. 

Beverages. — The question of beverages is of great im- 
portance in the treatment as well as in the etiology of dys- 
pepsia. Unfortunately we have to rely much more upon 
theory than upon actual, definite, scientific facts in. the 
determination of the role which they play in these two 
respects. 

Alcohol. — What is the influence which alcohol and 
alcoholic beverages exert upon digestion? How far can 
we permit their use, and under what form, in cases of 
dyspepsia? The older writers were divided on this point. 
Some held that alcohol increased the secretion of gastric 
juice, and favored digestion ; others, among them Claude 
Bernard, believed that this was the case only with small 
quantities and with drinks containing a small proportion 
of alcohol; others again looked upon alcohol as always in- 
jurious. Researches looking to the solution of this prob- 
lem have been made recently, but only in a qualitative 
way, and the conclusions arrived at by different investiga- 
tors are still contradictory. Gluzinski 1 divides the effect 

J "Ueber den Einfluss des Alkohols auf die Functionen des 
menschl. Magens" (Archiv fur klinische Medicin, vol. xxxix., p. 405). 



58 DISEASES OF THE STOMACH AND INTESTINE. 

of alcohol upon gastric digestion into two phases : in the 
first the process of digestion is suspended by reason of the 
presence of the alcohol and of its restraining action on 
pepsin ; in the second, when the alcohol has disappeared, 
there is an exaggerated secretion of hydrochloric acid 
which may be in two or even three times the normal 
amount. 

Wolffhardt holds ' that cognac in small quantity retards 
the digestion of starches and suspends it entirely when 
taken in larger amount. When given largely diluted he 
believes that it hastens the digestion of albuminoids, but 
suspends it when given in larger doses. Klemperer* 2 in 
opposition to Gluzinski, maintains that the motility of the 
stomach is increased rather than its secretion. 

That which takes place in alcoholic gastritis — which is 
in reality a rather complex condition in which gastritis 
and a toxic neurosis each play its part — can hardly give 
us much information as to the physiological role of alco- 
hol ; sometimes, indeed, there is an increase in the secre- 
tion of hydrochloric acid and sometimes a diminution 
(Hayem, A. Mathieu). We do not know whether an in- 
creased secretion does or does not always precede the 
diminished secretion ; we do not know whether all individ- 
uals do or do not react in the same way to the influence of 
alcohol, as it acts locally in contact with the mucous mem- 
brane or constitutionally as a poison in the blood. We 
must remember also that the researches to which we have 
referred have to do only with gastric digestion, and we 
know nothing whatever of the influence of alcohol upon 
duodenal digestion, which is perhaps more important than 
the other. 

Ought we then to give alcohol to dyspeptics, and if so, 
in what amount? In any case it should be given in small 
quantities and well diluted. It should not be taken on an 

1 "Ueber den Einfluss des Alkohols auf die Magenverdauung" 
(Alunchener medicinische Woclienschrift No. 35, 1890). 

8 " Alkohol und Kreosot als Stomachica" (Zeitschrift fur klinische 
Medicin, vol. xvii.). 



GENERAL CONSIDERATIONS ON DIET. 50 

empty stomach any more than should any other strong 
fermented drink. Its use should be forbidden in cases of 
increased secretion or of evident gastritis, especially in the 
gastritis and gastro-enteritis of alcoholic origin. Alcohol 
is perhaps better borne and less injurious when given in 
the shape of brandy or of rum largely diluted. 

Of course all that has been said applies only to the natural 
alcoholic beverages and not to the manufactured article. 
Unfortunately it is becoming more and more difficult to 
obtain genuine liquors, free from all falsification, a fact 
that is deplorable from every point of view. 

Wine. — One of the few points relating to dyspepsia and 
its etiology upon which everybody is in accord or nearly 
so, is the injurious action of red wine in most cases. The 
use of red wine ought to be suspended or even definitely 
abandoned in all cases of dyspepsia of even moderate in- 
tensity. It is often sufficient to vary the beverage in 
order to obtain a notable improvement. On the other 
hand, all forms of treatment are often of no avail unless 
the use of red wine is forbidden. It is possible that this 
injurious action of red wine is to be attributed especially 
to its acidity (5 or 6 parts per 1,000). 

White wine, especially when diluted with water, may 
often be substituted with advantage for red wine. It 
ought, nevertheless, to be taken in very moderate quantity. 

Beer. — When it is agreeable to the patient beer may be, 
in like manner, substituted for red wine. A very light 
beer, weak in alcohol, should be selected or else a heavier 
beer should be diluted with water. 

Table Waters.— Pure water of good quality is the best 
of beverages. It has only one disadvantage, and that is 
that persons accustomed to the taste and to the stimulation 
of fermented beverages do not take readily to the exclusive 
use of water. Table waters ' are those which contain little 
or no mineral matter. Their special advantage lies in 
their bacteriological purity. The presence of alkaline salts 
and of a more or less considerable amount of carbonic acid 
1 C. Paul and P. Rodet : " Les Eaux de Table, " Paris, 1892. 



60 DISEASES OF THE STOMACH AND INTESTINE. 

gas imparts to some of them an agreeable flavor. They 
increase the appetite in a moderate degree, and perhaps 
also the gastric digestion. It is not always well to use the 
natural gaseous waters continuously for a long period, and 
this applies with even more truth to the artificial gaseous 
waters. They ma3 r , however, be given with advantage 
for more or less prolonged periods, in cases of atonic nervous 
dyspepsia of moderate intensity, as this is an excellent 
means of stimulating both appetite and digestion. Care 
must be taken that these waters are not drunk in excessive 
amount, as they are then liable to prove injurious. 

Hot Drinks. — While net in favor of restricting all fluids, 
I am, nevertheless, convinced that the amount of liquid 
taken ought, in many cases, to be veiy much reduced, and 
I am in the habit of effecting this by instructing the pa- 
tients to take only hot beverages. This is a practice which 
I have borrowed from Germain See, and I have almost 
always had cause to congratulate myself on its adoption. 

The drinks are to be taken hot during meals to the ex- 
clusion of every kind of cold drink. The patient should be 
made to take hot, not merely warm water. Sometimes the 
addition of an aromatic will make it more acceptable. Hot 
weak tea, slightly sweetened, is sometimes taken readily; 
but some people cannot drink it, in the evening especially, 
as it excites them and prevents sleep. In such cases we 
may give a weak grog moderately sweetened, made with 
cognac or rum, which may be previously burned in order 
to deprive it of its alcohol. Certain infusions may also 
be used, such as infusion of camomile, of orange leaves, 
etc., according to the taste of the patient. 

Hpt drinks appear to us to have several very real advan- 
tage*. I]J^o first place their exclusive use leads to a 
diminish^ fc|stion of fluids; secondly, they exert a calm- 
ing influe^^H^ pain, on gastric hyperesthesia ; finally it 
is probable That thdy stimulate the gastric movements 
through a direct irritation of the smooth muscular fibres. 
Heat, in fact, excites contraction in the smooth muscular 
fibres in various parts of the body, as is shown, for exam- 



GENERAL CONSIDERATIONS ON DIET. Gl 

pie, in the treatment of metrorrhagia by hot injections ; 
and physiological experience tends to show that heat exerts 
the same action in the digestive tube. 

But, whatever the explanation, e very-day experience 
demonstrates the good effects of hot drinks. We need, 
therefore, pay but little attention to the theoretical objec- 
tions which have been raised against their use. 



PART III. 

TREATMENT OF THE PRINCIPAL CLINICAL FORMS OF 
DYSPEPSIA AND OF THE MOST COMMON SYMPTOMS 
OF GASTROINTESTINAL DISEASES. 

Clinical observation, aided by the methods of study 
which we have indicated above, enables us to recognize 
numerous symptomatic elements in the various morbid 
conditions of the digestive tract. We might take up these 
symptoms one after the other and indicate special modes 
of treatment which each one would individually demand, 
but this analytical method would be tiresome and would 
involve us in a number of useless repetitions ; we should 
lose sight of the whole and become swamped in details. It 
will be better to consider, not isolated symptoms, but the 
symptomatic complexus which may be viewed as a whole, 
constituting thus a clinical form of dyspepsia or a second- 
ary expression of definite diseases or lesions. 

The dyspeptic state ' may be divided into two main cate- 
gories, according as there is or is not an increased secretion 
of hydrochloric acid. This exaggerated secretion of the 
acid of the stomach has received the convenient appellation 
of hyperchlorhydria. This hyperchlorhydria, when it ex- 
ists, characterizes a whole series of morbid facts; it is the 
predominant element in them. 

When there is no exaggerated secretion of hydrochloric 
acid the thing of most importance to be considered is the 
degree of gastric, or rather gastro-intestinal, motility. 

It very rarely happens that the movements of the stom- 

1 A. Mathieu : "Traite de Medecine, " vol. iii. A. Mathieu and 
Remond (of Metz) , Societe Medicale des Hopitaux, 1891-92. 

62 



DYSPEPSIA AND GASTROINTESTINAL DISEASES. 63 

ach arc exaggerated ; more often the trouble is one of atony, 
and this motor atony may be coexistent with secretory 
atony. Various dyspeptic states are characterized espe- 
cially by nervo-motor atony, with or without a concomi- 
tant secretory atony. The latter consists chiefly in a di- 
minished secretion of hydrochloric acid, to which the term 
hypochlorhydria has been applied. 

When the motility of the stomach is sufficiently impaired 
we have gastric stasis and, in consequence of this stasis 
and of the reduced secretion of hydrochloric acid, a ten- 
dency to abnormal fermentations. Organic hyperacidity 
more frequently accompanies permanent dilatation. 

The painful element assumes sometimes a very great 
importance, and is occasionally the principal element in 
certain morbid states of the stomach and intestine; it de- 
serves to be made the subject of a special study in which 
would figure gastralgia and enteralgia, and gastric and 
intestinal crises. The medication indicated for these con- 
ditions is pre-eminently that which would be sedative in 
its action upon the tissues of the stomach and intestine. 

The treatment of vomiting will be taken up in a sepa- 
rate chapter, and we need offer no apology for devoting 
a special section to its consideration. 

On the side of the intestine we find two great sympto- 
matic complexuses which will be the object of a general 
study ; these two are constipation and diarrhoea. 

At the present day we cannot make a complete review 
of the morbid processes going on in the stomach and in- 
testine without including a study of auto-intoxications, 
and we shall therefore devote a chapter to gastrointesti- 
nal antisepsis. 

It will be more convenient also to group under one head- 
ing the treatment of the various hemorrhages of the stom- 
ach and intestine. 

If now to the preceding chapters we add one on the dis- 
orders of the appetite and on aperitive medication, we 
shall have before us the following table of the chapters 
which together will form the third part of this work: 



04 DISEASES OF THE STOMACH AND INTESTINE. 

Hyperchlorhydria, or excessive secretion of hydrochloric 
acid. 

Atonic nervo- motor dyspepsia, with or without dimin- 
ished secretion of hydrochloric acid. 

Permanent dilatation of the stomach. 

Gastralgia, enteralgia, gastric and intestinal crises. 

Disorders of the appetite, aperitive medication. 

Constipation. 

Diarrhoea. 

Gastro-intestinal antisepsis. 

Hemorrhages from the stomach and from the intes- 
tine. 

This scheme is based entirely upon pathological physiol- 
ogy and semeiology, and takes no account of the presence 
or absence of any anatomical lesion. We have been forced 
to adopt this division for the reason that in many cases 
there is nothing more difficult than to decide whether, to 
take an instance, there is or is not gastritis present, 
whether the gastritis is or is not the primary cause of all 
the trouble, or whether a previously existing neuropathic 
condition may not be responsible for everything. 

As we go along we shall take account, as far as may be 
necessary, of the bearing which the pathological anatomy 
of each condition may have upon its treatment, but in the 
present part of this work we shall not have to concern our- 
selves much with this question. 

We shall also treat in detail in this section of the thera- 
peutics of what was formerly called essential dyspepsia. 
Furthermore, the previous consideration of the treatment 
suitable for the various dyspeptic symptoms will enable 
us to shorten considerably the chapters relating to the 
actual diseases of the stomach and intestine, in which we 
shall find again these same symptomatic elements ; but in 
these chapters we shall come across another factor, the 
lesion, which may be of more importance in the pathologi- 
cal ensemble than its dependent dyspeptic condition. In 
the case of cancer of the stomach, for example, the can- 
cerous lesion itself is of much more importance than the 



DYSPEPSIA AND GASTKO-INTESTINAL DISEASES. 65 

diminished secretion of hydrochloric acid or than the re- 
duced motility of the stomach. Nevertheless this is of 
more value in the way of prognosis than as regards treat- 
ment ; the therapeutic indications derived from a symptom 
or from a collection of symptoms remain the same in mor- 
bid conditions of very diverse origin and nature. 
5 



CHAPTER I. 
Hyperchlorhydria. 

Definition. — Hyperchlorhydria is an excess of hydro- 
chloric acid in the gastric juice ; it is not a disease, but is 
merely a symptom common to different gastric conditions. 
Nevertheless, in a certain number of cases this increased 
amount of hj-drochloric acid is the most prominent symp- 
tom, one which serves justly to designate the entire mor- 
bid state. The time when the acid is excreted and its 
amount determine special clinical forms. 

We must distinguish three principal varieties : 

1. Hyperacidity occurs only during digestion, and is 
absent when the patient is fasting. 

2. Hyperchlorhydria appears in attacks, like gastric 
crises or fits of migraine. 

3. It is accompanied by hypersecretion and by dilatation 
of the stomach, and this continuous hypersecretion takes 
place equally during fasting and after meals (hyperchlor- 
hydria with continuous hypersecretion, Reichmann's dis- 
ease. ) ' 

The terms by which it has been proposed to designate 
hyperchlorhydria and the various clinical types under 
which it presents itself ought to be mentioned here. Un- 
der the pretext of making things clearer, writers have 
complicated what is in reality very simple. Hayem pro- 
poses the term hyperpepsia, which is incorrect, since 
what characterizes this state is the excess, not of digestive 
labor, but of the chlorine element, especially as it exists 
under the form of hydrochloric acid. Albert Robin pro- 

1 Bouveret and Devic : " La Dyspepsie par Hypersecretion Gas- 
trique : " 1892. 

66 



HYPERCHLORHYDRIA. 67 

poses the still worse name, gastric hypersthenia. 1 He 
ought to have called it at least "secretory hypersthenia," 
which is needlessly longer than hypersecretion. He dis- 
tinguishes among the acute forms the following vari- 
eties: 1. Acute paroxysmal hypersthenia of neurotic ori- 
gin. 2. Acute intermittent hypersthenia of central 
origin. 3. Acute hypersthenia of direct origin, that is to 
say, gastric or reflex. He considers only the acute forms. 

We shall study the second variety, the crises of hyper- 
chlorhydria, when treating of gastric crises, to which a 
special chapter will be devoted. We shall consider then 
here only intermittent, digestive, and simple hyperchlor- 
hydria and hyperchlorhydria with continuous hypersecre- 
tion (Reichmann's disease). 

Simple Hyperchlorhydria. — In the normal condition 
the acidity of the stomach during digestion does not ex- 
ceed at the most 1.80 to 2 per 1,000, but in cases of hyper- 
chlorhydria it may reach even 3 or 4 parts per 1,000. 
That which characterizes hyperchlorhydria is that this 
hyperaciditv is due to an excess of hydrochloric acid, 
either free or combined. We may find, for example, a 
total of 3 to 3. 50 parts per 1,000 of free and. combined hydro- 
chloric acid. This total of free and combined acid is what 
Hay em and Winter call chlorhydria; the expression is 
convenient and useful. 

The patients often present symptoms very similar to 
those of simple nervo-motor dyspepsia, such as weight and 
a feeling of malaise after eating, flatulence, regurgitation, 
constipation; but they have a tendency to suffer, more 
than nervo-motor dyspeptics, from pain coming on from 
three to five hours after meals. Nevertheless, in simple 
intermittent hyperchlorhydria the stomach empties itself 
completely of its contents in the intervals between meals, 
and there is neither continuous hypersecretion nor perma- 
nent stasis. 

Simple hyperchlorhydria may be met with in numerous 
morbid states, in neurasthenics and neuropathies of vari- 
1 Bulletin Medical, February 26th, 1893. 



68 DISEASES OF THE STOMACH AND INTESTINE. 

ous orders, in chlorotic individuals, and in those given to 
the abuse of alcohol ; in gastritis more rarely, exceptionally 
indeed ; in cancer of the stomach, etc. Finally, it probably 
constitutes in many cases the first degree of continuous 
hypersecretion. 

Con ti nitons Hypersecretion. — This condition is char- 
acterized, as its name would indicate, by an exaggerated 
and continuous secretion of gastric juice containing an ex- 
cessive proportion of hydrochloric acid. This acid is com- 
bined with the albuminoid substances that it meets with 
in the stomach ; it is free when it finds none of these sub- 
stances with which to combine. This is a matter of slight 
importance, and no useful purpose is served by distin- 
guishing different varieties according as the hydrochloric 
acid is free or combined. At an advanced period of the 
disease, when the glandular lesion has progressed suffi- 
ciently, hypersecretion persists, but the hyperchlorhydria 
disappears or sensibly diminishes. We may then find an 
exaggerated amount of fixed chlorides in the gastric juice, 
which are secreted without doubt by the mucous membrane 
become incapable of elaborating hydrochloric acid. The ac- 
centuated cases of continuous hypersecretion, called Reich- 
mann's disease after the author who first clearly described 
it, are accompanied by dilatation of the stomach and per- 
manent stagnation of its contents. 

Examination of the stomach while the patient is fasting, 
even in the morning, shows the presence in it of a liquid 
containing debris of food, especially of bread and of starchy 
substances, strongty acid and giving in very marked de- 
gree the reactions of free hydrochloric acid. Patients who 
still have an appetite suffer from severe pains in the stom- 
ach for quite a while after eating ; these pains, which are 
often very intense, sometimes end in an attack of vomit- 
ing. Sufferers from this trouble become emaciated al- 
though they often eat an abundance of food. 

Most of the phenomena observed in this disease can be 
explained by the continuous presence of hydrochloric acid 
and its irritating action on the gastric mucous membrane. 



HYPERCHLORHYDRIA. 69 

Nitrogenous food is well borne, and the pains cease during 
its digestion by reason of the temporary saturation of the 
hydrochloric acid, but they reappear as soon as the latter 
is found again in excess, to cease finally when it is rejected 
by vomiting or once more saturated. Starchy substances 
are ver3 r badly digested, for they simply swell up and re- 
main in the dilated stomach, a fact which furnishes an 
imperative indication in regard to the dietetic management 
of these cases. 

Dilatation of the stomach may depend upon various 
causes, such as spasm of the pylorus due to the irritation 
of a hyperacid gastric juice, nervo-motor atony of neuro- 
pathic origin, the accumulation of fluid and of undigested 
particles of food, and finally gastritis either primary or 
secondary. 

What is the nature of hyperchlorhydria? This is a 
question which is still the subject of much controversy 
and which we cannot stop to discuss at length in this place. 
The affection has been seen to occur in neuropathic indi- 
viduals as a consequence of some powerful emotion, and 
in tabetic subjects at the moment of the occurrence of gas- 
tric crises. On the other hand gastritis has always been 
found at autopsy, but we must remember that we have no 
accounts of autopsies made at an early period of the com- 
plaint. The neuropathic element exists beyond question 
in many cases, but the presence of gastritis has been ob- 
served in certain cases followed by autopsy ; may it not be 
that there are instances of hyperchlorhydria due wholly to 
a neuropathy with gastric determination, and others due 
exclusively to gastritis (acid catarrh of Jaworski) ? This 
is a question which is impossible of solution with the data 
at present in hand, and fortunately it is one of little im- 
portance as far as the matter of treatment is concerned. 
Nevertheless it is very probable that all cases of continuous 
hypersecretion with permanent dilatation end finally in 
gastritis, as we might presume they would in consequence 
of the irritation of the gastric mucous membrane by a su- 
peracid liquid. We are inclined to believe that there is 



70 DISEASES OF THE STOMACH AND INTESTINE. 

very often at first simply a neuropathic hypersecretion 
which terminates in true inflammation ; this is the mixed 
neurosis of Remond. At all events, simple hyperchlorhy- 
dria, if it persists long enough, is almost certain to pass 
into continuous hj^persecretion, and continuous hyperse- 
cretion ends in gastritis. This inflammation gives rise to 
simple ulcer, a frequent complication of hyperchlorhydria, 
and it leads as its final stage to destruction of the glandu- 
lar structure of the stomach and to incurable dilatation. 

Continuous hypersecretion is therefore a very grave dis- 
ease, incurable when it has once become pronounced and 
inveterate, and our efforts must consequently be directed 
to prevent its passing into the chronic stage. Treatment 
of simple hyperchlorhydria should therefore be instituted 
at the earliest possible moment and should be methodical, 
active, and persistent. 

Diagnosis. — A positive diagnosis of hyperchlorhydria 
cannot be made without a chemical examination of the 
gastric juice, but nevertheless certain clinical signs, taken 
in connection with the happy effect of diet and of a suita- 
ble medication, may render the existence of the condition 
highly probable. 

In this affection we find pain coming on some time after 
the ingestion of food and relieved by the taking of fluids, 
food, or alkalies. Albuminoid substances are better borne 
than the starches, in continuous hypersecretion, on the 
other hand, the pains are more intense and are often fol- 
lowed by vomiting. They frequently come on during the 
night and wake the patient. The stomach is dilated and 
is found to contain liquid even when the patient is fasting. 
The sufferers from this condition emaciate, and sometimes 
even become cachectic in appearance, although they have 
preserved their appetite and may even eat excessively. 
The urine of those suffering from simple hyperchlorhydria, 
who are well nourished, is rich in urea. The occurrence 
of hematemesis may indicate the supervention of simple 
ulcer, a complication, as we have said above, of hyper- 
chlorhydria. 



HYPERCHLORHYDRIA. 71 

All these symptoms may, however, prove deceptive, and 
several times we have found diminished secretion of hy- 
drochloric acid with organic hyperacidity when we had, 
from the symptoms alone, diagnosticated hyperchlorhydria. 
In certain patients there is a true hyperesthesia of the gas- 
tric mucous membrane, and the contact of a relatively 
small quantity of organic acids may give rise to phenom- 
ena precisely like those caused by the presence of hydro- 
chloric acid in excess. On the other hand there are cases 
of latent hyperchlorhydria, in which we may find an ex- 
cess of hydrochloric acid when the clinical signs would 
point rather to an insufficient secretion of this acid. 

A chemical examination of the gastric juice should, 
therefore, be made whenever possible, for hyperchlorhy- 
dria is a sufficiently serious disease with a sufficiently 
grave prognosis to render this examination well worth 
while. When it cannot be made we must be guided by 
the clinical signs and the results of an examination of the 
urine in instituting a tentative treatment. 

We may mention, in concluding this summary of the 
pathology and diagnosis of hyperchlorhydria, that Bou- 
veret and Devic have found tetany to be more often a 
symptom of this condition than of any other. 

Treatment. — The therapeutic indications are easily de- 
duced from what we have learned of the nature of hyper- 
chlorhydria and of continuous hypersecretion; and here 
again we can hardly separate the two conditions. We 
must — 

1. Diminish the causes leading to secretory stimulation 
of the gastric mucous membrane. 

2. Saturate the acid present in excess and, if possible, 
restrain its production so as to spare the mucous membrane 
from the irritation resulting from its contact. 

3. Prescribe the diet best suited to the chemical condition 
of the stomach. 

4. Combat the phenomena of gastro-intestinal atony, 
when they exist. 

5. Reduce the pain by remedies directed against it alone, 



72 DISEASES OF THE STOMACH AND INTESTINE. 

when it is not alleviated by the treatment indicated for 
the hyperchlorhydria. 

We shall consider now what are the hygienic or medi- 
cinal remedies proper to meet these indications. 

1. Diminution of the Causes of Secretory Excitation of 
the Gastric Mucous Membrane. — These are direct and 
indirect. By direct causes we understand those which 
may produce an immediate local stimulation of the stom- 
ach ; by indirect, those which act through the nervous sys- 
tem by provoking reflexly an increased secretion from the 
gastric mucous membrane. 

The causes of direct irritation are numerous. The mu- 
cous membrane of the stomach may be mechanically irri- 
tated by coarse food or by food which is insufficiently di- 
vided or improperly masticated. In certain patients the 
only cause which can be found for hyperchlorhydria is 
insufficient mastication (Bouveret and Devic, A. Mat- 
thieu). The question is often, it is true, very complicated, 
as is everything relating to biology. For example, per- 
sons who masticate badly are often forced by the nature of 
their occupations to eat their food very rapidly ; or they 
are so overworked and worried that they become neuras- 
thenic. Sometimes people who eat too rapidly without 
properly chewing their food are already neuropathic sub- 
jects, who lack method in taking their meals just as they 
do in everything else. Finally, insufficient mastication is 
accompanied by insufficient secretion of saliva, and certain 
experiments seem to demonstrate very clearly that the pres- 
ence of saliva is necessary to the proper performance of 
the digestive functions of the stomach. 

The substances which are capable of irritating the gas- 
tric mucous membrane are exceedingly numerous, and we 
shall mention only the chief of them: alcohol, strong 
liquors, spices and condiments of all kinds, and many 
drugs such as the iodides, bromides, ferruginous salts, 
naphthol (Hayem), etc., etc. We may perhaps include in 
the same category the toxic alkaloids of animal or vege- 
table origin, whence the injurious effect of high meats, 



HYPERCHLOEHYDRIA. 73 

strong cheeses, and the like. Acids, mineral or organic, 
may have the same injurious effect, even those secreted by 
the stomach itself, and it is easily imaginable that the irri- 
tation of the hydrochloric acid present may, acting in a 
vicious circle, provoke an increased excretion of the same 
acid. All individuals are not equally susceptible to the 
injurious action cf these irritants, and in certain cases 
there seems to be an actual predisposition to overstimula- 
tion of the stomach; we might well conjecture whether 
this predisposition is not, in many cases, both the conse- 
quence and the expression of a peculiar state of neuropathic 
irritation. We must admit indeed that lively emotions, 
disappointment, mental preoccupation, and intellectual 
overwork, are often the cause of an attack or of an exacer- 
bation of hyperchlorhydria. The gastric crises in locomo- 
tor ataxia are accompanied now and then by an increased 
secretion of hydrochloric acid, as may be shown by an ex- 
amination of the contents of the stomach at such times. 
We occasionally see the symptoms of neurasthenia and of 
hyperchlorhydria develop simultaneously, and it would be 
difficult to determine which is the primary condition. 

We can readily understand how the simultaneous action 
of these different factors may intensify the effect, and how 
much more exposed to hyperchlorhydria may be the neu- 
ropathic, the gouty, the neurasthenic when the gastric mu- 
cous membrane is subjected to repeated chemical or me- 
chanical irritation (as by alcohol, for example), or when 
they themselves are subjected to influences likely to in- 
crease their nervous condition, such as intellectual over- 
work, great disappointment, undue solicitude about health, 
financial matters, and the like. It, is evident then that 
our first object must be to suppress as far as possible all 
causes of irritation, direct or indirect. When we come to 
treat of diet we shall show how to reduce to a minimum 
irritation of the stomach from food. 

According to the degree of the disease it will be proper 
to take the patient away more or less from his habitual 
preoccupations. All possible causes of cerebral fatigue or 



74 DISEASES OF THE STOMACH AND INTESTINE. 

of mental distress must be suppressed. In grave forms of 
the disease, in cases of continuous hypersecretion, with a 
tendency to cachexia, the patient ought to give up his 
business entirely and to seek absolute repose, if not in bed, 
at least in his own room. The latter is all the more nec- 
essary since we are often obliged to prescribe a dietary 
which would be insufficient for a man in active life. It is 
a particularly delicate task for the physician to induce the 
patient to seek this physical, mental, and moral repose, 
and it will often require the exercise of much tact to ac- 
complish it, He must gain the entire confidence of his 
patient and appreciate thoroughly all the conditions of his 
life, from a moral as well as from a material point of view. 

2. Saturation of all Acid in Excess and, if possible, Re- 
striction of its Production.— The action of a liquid over- 
charged with hydrochloric acid is certainly injurious to 
the gastric mucous membrane. Pain felt by patients sev- 
eral hours after digestion, when there is no liquid in the 
stomach to dilute the hydrochloric acid or nitrogenous 
substances to saturate it, is certainly duo to this cause. 
The irritation arising from this permanent contact may in 
the end cause gastritis and round ulcer. Furthermore, 
although in general nitrogenous substances are readily di- 
gested in surroundings so rich in hydrochloric acid, and 
doubtless also in pepsin, it is not the same with starchy 
substances, which in an acid medium would be no longer 
normally influenced by the saliva. They swell up and are 
in part retained in the liquid which remains in the dilated 
stomach, and they often give rise to fermentations which 
add an organic hyperacidity to the hyperchlorhydria al- 
read} T present. 

But this is not all, for it is probable that the hyperacid 
wave of fluid from the stomach which is poured out into 
the duodenum interferes with intestinal digestion. Pa- 
tients with hyperchlorhydria are then really deprived of 
carbohydrates, whence their emaciation, in spite of their 
appetite which is sometimes excessive. The object of the 
physician is, therefore, to saturate this injurious excess of 



HYPERCHLORHYDRIA. 75 

hydrochloric acid and to restrict its production. It is 
much more easy to meet the first indication than the 
second. 

Antacid Medication. — Nitrogenous foods, milk espe- 
cially, contribute in large measure to the saturation of the 
acid in the stomach, and consequently to the protection of 
the mucous membrane against its own secretion. But 
they do not suffice, for as soon as they are digested the 
hydrochloric acid becomes again free and ready to work 
mischief. Now we can neither multiply indefinitely the 
number of meals nor give milk in unlimited amount to 
patients who have or who will have gastric dilatation and 
stasis. We are obliged, therefore, to have recourse to al- 
kalies to saturate the excess of hydrochloric acid. We 
may even, when the patients are fed exclusively on milk 
and meat powder, as Debove has proposed, endeavor to 
suppress completely gastric digestion. This indication is 
very clear when there is an ulcer present or threatening. 
On the other hand, we must not continue indefinitely the 
administration of alkalies in large doses. They are indi- 
cated only when pain exists that does not yield to the in- 
gestion of food. Whenever possible the use of alkalies 
should be temporary or at least intermittent. 

We must see first how much acid there is that needs to 
be saturated, and we shall show then by means of what 
alkalies, and in what doses employed, we may attain this 
end. We do not yet know exactly how much gastric juice 
the stomach of man secretes. 

" A dog weighing 18 kilogrammes," says Beclard, " gave 
us an average of 72 grammes of gastric juice an hour. 
The quantity of gastric juice secreted in the human being 
has been estimated by Bidder and Schmidt, in the case of 
a woman having a gastric fistula, at more than 500 
grammes an hour. Taking into consideration the differ- 
ence in weight, we have here nearly the same proportion 
as in the case of a dog." 1 Assuming that this secretion 
is continued in the same proportion for three hours only 
1 Beclard : "Traite de Physiologie," 7th edition, vol. i., page 90. 



76 DISEASES OF THE STOMACH AXD INTESTINE. 

after each meal, we should thus have four or five litres of 
gastric juice; and on these figures Debove has based his 
treatment of round ulcer by alkalies in large doses. 

In the case of an acidity of 3 parts per 1,000, an amount 
that is often surpassed in hypersecretion of hydrochloric 
acid, we obtain figures much higher than would a priori 
be supposed, that is to say, 12 to 15 grammes at least of 
hydrochloric acid which we should have to saturate in 
order to render the gastric juice neutral. 

Taking the chemical equivalents we find that to saturate 
1 gramme of hydrochloric acid we require 1.48 grammes 
of bicarbonate of soda, so that from 20 to 25 grammes of 
bicarbonate of soda would not be too much. But as this 
salt has certain disadvantages, and as 25 grammes of bi- 
carbonate of soda would be disposed of with difficulty by 
certain patients, experiments have been made to determine 
whether it would not be better to make use of other alkaline 
bases. 

Boas, 1 taking as a starting-point these chemical equiv- 
alents, has compared calcined magnesia and ammonio- 
magnesian phosphate to bicarbonate of soda. One part of 
calcined magnesia and two parts of ammonio-magnesian 
phosphate correspond to four parts of bicarbonate of soda. 
According to this a mixture containing one part of cal- 
cined magnesia and two parts of ammonio-magnesian 
phosphate would correspond to eight parts of bicarbonate 
of soda, and if to this mixture we add four parts of bicar- 
bonate of soda we obtain the equivalent of twelve parts of 
the soda salt. One disadvantage of this substitution is 
that neither the magnesia nor the ammonio-magnesian 
phosphate is soluble in water. But we have a number of 
times employed successfully mixtures similar in composi- 
tion to those above mentioned. 

The calcined magnesia would be especially indicated 
in cases in which there is a tendency to constipation, 
or, by reason of its great absorbent power, in cases in 

1 " Allgemeine Diagnostik und Therapie der Magenkrankheiten," 

1890. 



HYPEKCHLORHYDEIA. 77 

which there is an undue amount of gas in the stomach and 
intestine. 

As to ammoino-magnesian phosphate, Hay em justly 
remarks that he does not know the effect which its pro- 
longed administration would exert upon the gastric mu- 
cous membrane. 

These three substances are, however, not the only ones 
which may be used. We may employ various other salts 
of soda, potassium or lime salts, other kinds of magnesia 
or subnitrate of bismuth. 

Sodium Salts. — The bicarbonate is by far the most fre- 
quently prescribed salt notwithstanding its few disad- 
vantages. Its taste renders it disagreeable to certain 
individuals; it is not often, however, that we have to 
abandon its use on that account. It may be given in 
water, in milk, or in wafers. Upon coming in contact 
with a hyperacid gastric juice it may give rise to an 
abundant formation of carbonic acid, producing thereby a 
disagreeable tympanism of the stomach or even, as I have 
seen, an actual sensation of suffocation. Certain patients, 
when under the influence of large doses of bicarbonate of 
soda, suffer from pains in the kidneys and from irritation 
of the bladder. There is nothing very serious in that, 
however, and we are no longer in dread of the alkaline 
cachexia with which Trousseau and Pidoux have fright- 
ened physicians of former days. Nevertheless we may 
find ourselves obliged to discontinue the use of the bicar- 
bonate and to have recourse to other alkalies. 

Rabuteau has urged the adoption of the sesquicarbonate, 
but has not succeeded in dethroning the bicarbonate. 

Many other salts of soda, for example, the benzoates, the 
lactates, the malates, etc., might, without doubt, be sub- 
stituted for the bicarbonate and might have, in certain 
cases, special advantages of their own. Thus, the benzoates 
might be employed when fermentation was present, or the 
lactic acid of the lactates might have a useful action in 
certain cases. These are, however, merely hypotheses 
which must be verified by clinical experience. 



78 DISEASES OF THE STOMACH AND INTESTINE. 

In concluding this enumeration of the sodium salts we 
must not omit the mention of medicinal soap or almond 
soap with sodium base. It has been prescribed by Sena- 
tor in pill form with a view of alkalinizing the intestinal 
juice (Hayem). 

Potassium Salts.- — These salts are not much employed 
in France, as their toxic action is feared, especially their 
toxic action upon the heart. However, many authors 
speak well of liquor potassae and suggest that it might be 
employed with advantage. It is made in such proportion 
that one part of the solution contains .08r> part of potash, 
so that 15 grammes of liquor potassae would be required 
to saturate 1 gramme of hydrochloric acid. To saturate 
the amount of acid present in hyperchlorhydria we should 
require from 15 to 20 grammes of potash, that is to say, 
200 to 300 grammes of liquor potassa?, an amount which it 
would be evidently impossible to give. So that although 
this preparation might be useful in other conditions when 
alkalies in small dose are indicated, it is of no service 
when it is desired to give large doses of an alkali. 

( 'a lei urn Salts. — These salts have been used for a long 
time in the treatment of diseases of the stomach. Lately 
Germain See has recommended especially the chloride and 
the bromide.' 

Lime water is frequently employed; this is a saturated 
solution, which contains, however, only 1.28 grammes of 
lime per litre. Referring again to the chemical equiva- 
lents, it is easy to calculate that one litre of lime water 
would saturate hardly more than one gramme of hydro- 
chloric acid. As an equivalent, therefore, of the 20 to 25 
grammes of bicarbonate of soda given by Debove in round 
ulcer we should have to administer more than 10 quarts of 
lime water a day. Nevertheless, this water produces ex- 
cellent effects in hyperchlorhydria and in simple ulcer. 
As it is given only in moderate doses (100 to 200 grammes 
on an average), it is evident that there is some other ele- 
ment than its alkalizing power upon which its favorable 
1 Academie de Medecine, March 8th, 1892. 






HYPERCHLOEHYDRIA. 79 

action depends. It is probable that its good effects are 
due to the role that lime plays in the coagulation of milk 
in the presence of the gastric rennet ; it is possible also 
that it exerts a sedative effect upon the mucous membrane 
of the stomach. Lime water goes naturally, therefore, 
with milk, to which it is added as a matter of routine. 

Lime may be dissolved in sweetened water in a much 
larger proportion than in pure water; this is probably due 
to the formation of a saccharate. Use has been made of 
this property to administer lime in a more concentrated 
form than it is in lime water. Trousseau used to give 
from 1 to 2 grammes of saccharate of lime to children 
and from 5 to 10 grammes to adults. Debove has also 
placed saccharate of lime among the remedies which may 
be used to render the gastric juice neutral. 

Carbonate of Lime. — Powdered crab's eyes and prepared 
chalk were much employed in former times, but at present 
we use only prepared chalk obtained by precipitation. 
The latter is often mixed with bicarbonate of soda, but 
this mixture should be very perfectly made if we would 
avoid the possible production of concretions in the intes- 
tine. 

Mode of Administration of Alkalies. — As a general 
rule, when alkalies are to be given in the treatment of hy- 
perchlorhydria, they should be administered some time 
after meals and just before the period at which the gastric 
pains ordinarily appear. They may be given in divided 
doses in such a way as to saturate the hydrochloric acid 
in proportion as it is being produced. In this way also 
we are constantly replacing in the stomach the alkaline 
bases which may have been washed out through the pylorus 
or have been absorbed ; we neutralize the hydrochloric acid 
at the very moment that it is in excess, at the moment that 
it is no longer chemically masked by the albuminoid sub- 
stances in process of digestion. If it is found desirable to 
administer alkalies during a meal they should be taken 
strongly diluted, under the form of Yichy or Vals water, 
for example. 



80 DISEASES OF THE STOMACH AND INTESTINE. 

The amount of alkalies given should be in proportion, as 
far as possible, to the absolute quantity of hydrochloric 
acid secreted by the mucous membrane of the stomach ; a 
smaller dose is therefore indicated in simple hyperchlorhy- 
dria than in hyperchlorhydria with continuous secretion. 
It will not be so very difficult to determine approximately 
the proper amount of alkali if a chemical examination of 
the contents of the stomach has been made. The pain is 
an excellent guide in this respect, for it ought to be en- 
tirely subdued by alkalies given in a proper way, at suita- 
ble intervals and in sufficient doses. 

It is a point that would seem to be well established that 
bicarbonate of soda, given in small doses on an empty 
stomach, increases the secretion of the gastric juice and 
the production of hydrochloric acid. The drug ought 
therefore never to be given in this way in cases of hyper- 
chlorhydria. 

A course of treatment at Vichy or Vals may suffice to 
bring about an amelioration of the symptoms in cases 
of simple hyperchlorhydria of moderate intensity. The 
waters should be taken during and after meals, and their 
action may be increased by the use of the powders obtained 
by the evaporation of the waters. The patients will at 
the same time derive the benefits accruing from a climatic 
treatment. 

But in cases of actual hypersecretion there is nothing to 
be gained by a visit to the Springs, and, as Bouveret and 
Devic justly remark, they will do much better at their own 
homes than in a hotel or boarding-house, and will be able 
to follow more exactly the severe regime thatReichmann's 
disease demands. 

To neutralize the gastric juice and to lessen the effect of 
its undue richness in hydrochloric acid is well ; but it is 
much better to prevent the exaggerated production of the 
acid, and to arrest the hypersecretion when it exists. Can 
we do this; have we any remedies which we can make use 
of for this purpose? 

It was natural to think of atropine, and some authors 






HYPERCHLORHYDRIA. 81 

have seen good effects from its use. We have employed 
it several times, but, like Bouveret and Devic, we have 
never seen it produce any good result. 

According to Jaworski, Ewald, and Hayem sulphate of 
soda has the property of reducing the rate of secretion of 
hydrochloric acid. Hayem even claims that the use of 
Carlsbad water may lead to a total disappearance of hydro- 
chloric acid, to anachlorhydria. He gives a small quan- 
tity of sulphate of soda, or of Vichy water containing from 
4 to 6 grammes of this salt, every morning before break- 
fast, to patients suffering from hyperchlorhydria. 

We must not forget that the most important thing is to 
reduce to a minimum the direct or indirect stimulation of 
the gastric mucous membrane. This is perhaps also the 
best means of diminishing the hypersecretion. 

It is quite true that we may, by feeling our way, finally 
arrive at a successful treatment of cases of this kind ; but 
it is certain that it is much better to base our treatment 
upon exact data derived from the chemical examination of 
the contents of the stomach, and to observe its effect by 
means of examinations repeated from time to time. The 
dangers resulting from hypersecretion, which menaces all 
patients with hyperchlorhydria, make examinations of 
this class well worth the physician's while, especially as 
they can be conducted with less discomfort to the patient 
than would be caused by the administration of an emetic. 
Still, when the patient obstinately refuses to submit to a 
direct examination we must necessarily grope our way, 
relying upon diagnostic probabilities. 

3. Diet. — The question of the alimentary regime of 
patients with hyperchlorl^dria is answered in different 
ways by different authors. Some, and these are the most 
numerous, rely especially upon a nitrogenous diet, while 
others prefer a vegetarian one (Dujardin-Beaumetz, Bar- 
det). 

If we consider that patients with hyperchlorhydria as a 
rule digest meat very well by reason of the habitual rich- 
ness of their gastric juice in hydrochloric acid and in 
6 



82 DISEASES OF THE STOMACH AND INTESTINE. 

pepsin, and that the starchy foods are not completely di- 
gested, but merely swell up, and that stagnation with acid 
fermentation tends to become chronic with them, we are 
naturally led to put them upon an almost exclusive nitro- 
genous diet, or in any case one in which the nitrogenous 
element predominates; and this all the more since the dis- 
solved albuminoids mask and neutralize the hydrochloric 
acid, forming temporary combinations with it. Dujardin- 
Beaumetz and Bardet have been led to prefer what they 
call a vegetarian diet (see above) because of the stimula- 
tion to the gastric mucous membrane that meat produces; 
under its influence there is an exaggerated secretion of the 
gastric juice. This fact has, indeed, been confirmed by 
Hayem, who has made some special experiments in this 
line. The argument has much less importance if we re- 
member that these patients usually receive large doses of 
bicarbonate of soda, given to combat the effects of the 
exaggerated secretion of hydrochloric acid. 

But in any event the treatment should vary according to 
the different forms and degrees of hyperchlorhydria. 

We must remember in the first place that the strict ap- 
plication of the general rules which we have laid down for 
the diet of dyspeptics is indicated ] >re-eminently in cases 
of hyperchlorhydria. In these cases more than in any 
others it is absolutely necessary that the food should be 
finely divided and should contain no indigestible residue; 
they must avoid irritating dishes of all kinds, spices, alco- 
holic liquors, red wine, and all fermented articles of food 
or drink. In special cases it may be necessary also to 
avoid acids of all kinds and to reduce in large part the 
amount of fatty substances consumed, because of the stag- 
nation which accompanies the grave forms of hypersecre- 
tion. 

In cases of continuous hypersecretion accompanying 
hyperchlorhydria it would be absolutely impossible to put 
the patient upon a vegetable diet. Bread and the debris 
of starchy and of green vegetables remain in the stomach 
and become at once a cause of new irritation and of pro- 



HYPERCHLORHYDRIA. 83 

gressive dilatation. In such cases the patients often suffer 
from very severe attacks of pain, ending in vomiting. The 
most appropriate treatment in the early stages of this condi- 
tion is a milk diet with large doses (15 to 25 grammes) of 
bicarbonate of soda or an equivalent amount of some other 
alkali according to the indications given above. We have 
said several times that it is better to give the alkaline salt 
some time after the milk, and the following is our ordi- 
nary method of procedure : The patient drinks a pint of milk 
in the course of fifteen or twenty minutes every two hours ; 
then, an hour or an hour and a half after drinking the 
milk, he takes a suitable dose of the alkali in a little milk 
or water or in wafer. The patient takes in this way about 
three quarts of milk in six or seven doses. It is well to 
reserve a little milk and a dose of the alkali for the night, 
as there are often, in these grave forms of hyperchlorhy- 
dria, very severe nocturnal attacks of pain. At the same 
time the patient is kept at rest and if necessary in bed ; 
under these conditions the milk diet suffices, at least tem- 
porarily, to maintain the strength. 

We may also, if there are no special indications against 
the passage of the sound, practise gavage with alkalinized 
meat powder in the same way as Debove does in the case 
of simple ulcer. We may thus introduce at one sitting, 
afterward at two, from 60 to 80 grammes of meat powder, 
the amount being increased later to from 100 to 200 
grammes. 

At a later period, when a certain improvement has been 
obtained, when the pains have disappeared, the hyperse- 
cretion has diminished, and the stomach in the morning is 
found to contain a much less quantity of acid liquid, we 
may try to give a small amount of starchy food ; the great 
difficulty will be, however, to bring the stomach to toler- 
ate it. We can easily give a large quantity of nitrogenous 
food and, thanks to the milk, a sufficient amount of fat, 
but it is much more difficult to cause the starchy substances 
to be well borne and digested. 

We may add a certain quantity of lactose, say from 60 



84 DISEASES OF THE STOMACH AXD INTESTINE. 

to 100 grammes a clay to begin with, to the milk; but care 
must be taken to see that this milk-sugar is well borne and 
that it does not contribute to increase the gastric acidity 
by the production of lactic acid. It will be proper later to 
give well-cooked starchy matters in the form of tapioca, 
bread, or flour soups made with milk. 

Bouveret advises that the starchy foods be given in the 
morning after the stomach has been washed out. At the 
same time a dose of bicarbonate of soda may be adminis- 
tered in order to alkalinize the gastric juice and to permit 
of the action of the saliva. It would be rational in these 
cases to give diastase, maltine, or maltose. This method 
is certainly very logical, but there is one objection to it, 
and this is that it is more harmful than beneficial to wash 
out the stomach every day in cases of hyperchlorhydria, 
for it acts as a stimulant to the gastric secretion. As an 
antiseptic measure it is sufficient to practise lavage two or 
three times a week, and we might take advantage of these 
times to administer starchy foods in the manner recom- 
mended by Bouveret. We have had no personal experi- 
ence with this practice, but we have succeeded re< entiy in 
bringing very marked relief to a patient with stasis by the 
simple use of milk, lactose, milk soups, and meat powder 
given through a tube. The patient gained twelve pounds 
in weight in the course of six weeks, and whereas formerly 
from 800 to 1,200 grammes of liquid could be collected from 
his stomach in the morning, now we can get only 100 to 
150 grammes. 

As the case improves we may give eggs, lightly pulped 
meat, and finally the various purees, approaching in this 
way the vegetarian regime of Dujardin-Beaumetz ; the 
latter is, however, an ideal which we can reach only after 
a considerable time and sometimes without an3^ hope of 
being able to maintain it for long periods. 

Let us see now what is the diet most suitable in a case 
of hyperchlorhydria of moderate intensity, without contin- 
uous hypersecretion or permanent stasis. There will be 
an acidity of 2 or 3 parts per 1,000 at the end of an hour 



HYPERCHLORHYDRIA. 85 

after Ewald's test meal (two ounces of bread and half a 
pint of water or weak tea), with a tendency to an exagger- 
ated secretion of the gastric juice as is shown by the greater 
quantity of fluid extracted from the stomach in these con- 
ditions. As a subjective symptom we see rather severe 
pain coming on several hours after a meal, especially in 
the afternoon or more rarely at night. These patients often 
of their own accord make a lighter meal in the evening 
than at noon, and it is well to encourage this plan in those 
who follow it and to counsel it to those who have not yet 
adopted it. Sometimes there is a slight tendency to flat- 
ulence after meals, and constipation is almost always 
present. 

The patients should live exclusively on meat, eggs, fish, 
dairy products, and mashed potatoes. They ought to eat 
little bread ; from three to five ounces of stale bread a day 
should suffice. For drink they should take milk or water, 
the latter pure or alkaline (Vichy or Vals) . Hot drinks 
seem to exert some good effect in reducing the amount of 
flatulence. As improvement takes place very light beer 
or beer diluted with water may be permitted. Gradually 
the attempt may be made to add starches to the diet, as 
has been said above. In dealing with patients of this class 
one cannot insist too strongly upon the absolute necessity 
of abstaining from everything that may irritate the stom- 
ach, and especially from alcoholic liquors and red wine. 
We must not forget that they are constantly menaced by 
continuous hypersecretion, and that they can avoid it only 
by minute hygienic precautions observed for a very long 
period of time. Dyspeptics of this class are often alcohol- 
ics ; this is an etiological point that we ought not to forget, 
for it is full of instruction for us from a dietary point of 
view. 

These patients are subject to exacerbations of longer or 
shorter duration, but in an interval between these attacks it 
is probable that they would derive benefit from a course of 
the waters at Vichy or Vals, upon condition, however, that 
none of the indications before mentioned be disregarded. 



86 DISEASES OF THE STOMACH AND INTESTINE. 

We now come to very mild cases of hyperchlorhydria, 
to those on the border-land between simple nervo-motor 
dyspepsia and hyperchlorhydria. The vegetarian dietary 
of Dujardin-Beaumetz might suit these, but these only. 
They might also derive benefit from a course of alkaline 
mineral waters, but with the strict understanding that they 
are not to be taken for sufferers from hyperchlorhydria, 
for they ought never, for example, to be allowed to drink 
alkaline waters while they are fasting. They would be 
helped by a rest in the country, properly regulated walks, 
freedom from all care, and a very simple diet as free as 
possible from all stimulating qualities. 

Treatment of the Symptoms of Gastro-Intestinal Atony. 
— This condition is not very uncommon in cases of hyper- 
chlorhydria. Permanent dilatation with stasis is almost 
of necessity present in severe cases accompanied by hyper- 
secretion when the disease has lasted a certain time. We 
may ask ourselves whether, in advanced eases, the relaxa- 
tion of the stomach walls may not be due in great part to 
the gastritis; yet it is certain, if we may he permitted to 
judge from the improvement seen in some instances, that 
the atony often is of great importance at the beginning. 
Whichever hypothesis may be correct, the course to be 
pursued remains very nearly the same; we must avoid 
with the greatest care all overloading of the stomach. It 
will be hardly possihle to overload the stomach when the 
mode of feeding above indicated is followed out, but in any 
case there can be no accumulation of indigestible detritus, 
such as tendinous fibres or fatty cellular tissue derived from 
the meat, or cellulose, vegetable fibres, or starchy matters 
in excess coming from the vegetables ingested. 

Washing out the stomach from time to time will be of 
advantage, but this ought not to be done too often on ac- 
count of its irritating effect upon the gastric mucous mem- 
brane. 

Meat powder may be given in hot water so as to stimu- 
late the smooth muscular fibres of the wall of the stomach 
to contraction, but all measures having a tendency to in- 



HYPERCHLORHYDEIA. • 87 

crease the movements of the stomach and intestine should 
be employed with great caution in cases in which there is 
continuous hypersecretion ; we shall refer to these meas- 
ures more particularly when we come to treat of dyspepsia 
resulting from atony. We must not forget that it is nec- 
essary to reduce to a minimum everything which may 
stimulate the mucous membrane of the stomach to still 
greater secretion in these cases in which hypersecretion 
already exists. 

For the same reason we ought to have recourse to ene- 
mata rather than to purgatives in treating the constipation 
which is very commonly present in patients of this class. 

In cases of simple hyperchlorhydria we often see phe- 
nomena of flatulence and of atony similar to those met with 
when this condition is not present. These phenomena 
may be attacked with more vigor the less pronounced is 
the hyperchlorhydria, and many of the patients indeed 
may be put at once upon a treatment directed against the 
atony. 

Treatment of the Pains not Amenable to that directed 
against the Symptom of Hyperchlorhydria Alone. — In gen- 
eral these pains are relieved by a suitable diet and the ad- 
ministration of alkalies, and when this result is not pro- 
duced we must see whether it is not because the alkali is 
given in insufficient dose or at unsuitable intervals after 
meals. However, there are cases in which we are forced 
to resort to the administration of gastric sedatives in 
combination with the alkalies. We shall lay down the 
rules for giving these remedies in a subsequent chapter, 
and need not consider the subject at greater length here. 



CHAPTER II. 

NERVO-MOTOR DYSPEPSIA (ATONIC OR ASTHENIC 
DYSPEPSIA). 

We apply the general term nervo-motor dyspepsia to 
that form of dyspepsia in which the disturbance of the 
gastro-intestinal motility, especially atony, seems to be the 
most important phenomenon. It is also often, but not al- 
ways, accompanied by secretory atony and diminished 
production of hydrochloric acid. In typical cases of this 
variety of digestive trouble, the most prominent symptoms 
are those due to nervo-motor derangement, which is trans- 
lated by a tendency to passive distention, atony, of the 
different segments of the digestive tube. These phenomena 
are most marked in the stomach and large intestine, by 
reason of the greater calibre of these parts. According as 
these morbid manifestations are more marked in the stom- 
ach or in the colon, according also to their degree and to 
the presence or absence of a diminished secretion of hydro- 
chloric acid, we find more or less pronounced clinical 
varieties. 

There is no doubt that there are a certain number of 
these cases in which a true chronic inflammatory lesion of 
the digestive mucous membrane is present. Gastritis in 
particular is very apt to come on in patients of this class 
in consequence of the disturbance of motility; but when it 
gives rise to no prominent symptoms or is even unrecog- 
nizable it is actually of little importance. There is, in- 
deed, nothing more difficult to diagnose than gastritis and 
sometimes enteritis; the uncertainty in this regard is so 
great that clinicians of equal attainments admit or deny 
the existence of catarrhal inflammation in cases in which 

88 



NERVO-MOTOR DYSPEPSIA. 89 

the symptoms are absolutely identical. But, as we have 
said before, this is of little importance. 

To show how much we may be embarrassed in deciding 
whether the nervo-motor or the catarrhal element is the 
primary one, let us take, for example, what is called alco- 
holic gastritis. In some this shows itself by the symptom 
of hyperchlorhydria, in others by the opposite condition of 
diminished secretion of hydrochloric acid (Hayem), even 
when the duration of the poisoning may be unable to ac- 
count for these opposing facts. Gastritis surely is not the 
only element present; we know that the entire nervous 
system is involved and is excited by the action of the alco- 
hol, and that alcoholic subjects are always neuropathic. 
The dyspepsia from which they suffer is certainly also 
nervous in large measure, and it is very difficult to deter- 
mine the particular role of these diverse pathogenic ele- 
ments in the production of the morbid ensemble. We are 
not even sure of the exact nature of the mucous membrane, 
and we know that the matter expelled by morning vomit- 
ing contains much saliva (Frerichs). 

We may then, in a general way, ignore the question of 
the presence or absence of gastritis in cases of genuine 
nervo-motor dyspepsia. We have, in the preceding re- 
marks, endeavored to show clearly the signification, es- 
pecially clinical, which we attribute to this term. Nervo- 
motor dyspepsia in this sense corresponds in general to 
what was formerly called flatulent d3 T spepsia, and also to 
that form which writers, especially German writers, call 
catarrhal gastritis. 

Germain See ' was the first who definitely isolated this 
clinical variety of dyspepsia. At one time when chemical 
researches had not acquired the precision that they have 
at the present day, he made a distinction between pseudo- 
dyspepsias of motor origin from true dyspepsia of chemi- 
cal nature. This view is open to attack, but, nevertheless, 
under the incorrect term pseudo-dyspepsia he distinguished 
clearly a symptomatic complex of actual clinical existence 
lu Des Dyspepsies Gastro-Intestinales." 



90 DISEASES OF THE STOMACH AND INTESTINE. 

and of frequent occurrence. He deserves credit also for 
demonstrating very clearly that the intestine is concerned 
equally with the stomach in digestive disturbances. 

In an article published in the Revue de Medecine for 
1885, we have taken up with him and carried still further 
the study of this form of dyspepsia. The researches which 
we undertook later with Remond in the service of Professor 
Debove enabled us to show that chemical examination only 
confirms the existence and the frequency of nervo-motor 
dyspepsia ' with predominating atony. 

Hayem gives a very limited place to atonic dyspepsia, 
but this is because he attributes a great importance to 
what, in our view, are minute variations in the proportion 
of free or combined hydrochloric acid. He multiplies 
chemical divisions without any evident clinical utility. 
He also forgets that he examines the functions of the stom- 
ach only, and does not take sufficient account of the intes- 
tine, which is, however, even more important than the 
stomach in normal digestion and in quite a number of 
pathological conditions. 

Simple nervo-motor dyspepsia, as we understand it, 
includes the great majority of cases in which there is 
neither hyperchlorhydria, permanent stasis, nor organic 
hyperacidity; it represents more than a third, perhaps a 
half of the cases of dyspepsia. 

Patients suffering from the most common form present 
the following symptoms: More or less immediately after 
eating they have a sensation of weight at the pit of the 
stomach and frequently a feeling of suffocation. They are 
obliged, in order to breathe more easily, to loosen their 
garments, and often they have eructations of gas, causing 
much relief. Respiration is difficult, the face is congested ; 
they have a sensation of torpor, of general malaise, and of 
heaviness in the head. They suffer from somnolence and 
find themselves incapable of any intellectual labor. The 
tympanism from which they suffer is often as much intes- 

1 Societe Medicale des Hopitaux, 1891-92. Debove and Remond, 
"Lavage de l'Estomac" (Bibliotheque Charcot-Debove) . 



KERV0-M0T0R DYSPEPSIA. 91 

tinal as it is gastric. The patients are habitually consti- 
pated and frequently suffer from hemorrhoids and from 
muco-membranous enteritis. In some cases these intesti- 
nal symptoms predominate and mask those arising from 
the stomach ; at other times there is an alternation in pre- 
cedence between the gastric and the intestinal manifesta- 
tions. 

These patients are above all flatulent, although this 
symptom is, in exceptional cases, less marked ; the sensa- 
tion of fulness, of gastro-intestinal distention, is less no- 
ticeable, sometimes almost absent. There is after meals 
a feeling of weight, sometimes even a burning sensation at 
the pit of the stomach. This is, it would seem, although 
it is not actually proven, an indication of a tendency to 
stasis and to secondary or, better, excessive organic fer- 
mentation. In rare instances the gastric pain becomes 
quite intense, and almost always there are cramps or a 
burning sensation which might almost be characterized as 
pain. Certain patients, moreover, seem to have a true 
hyperesthesia of the gastric mucous membrane, so that a 
degree of hyperacidity, which would be unnoticed by some, 
becomes the cause in them of acute pain. 

Vomiting is rare ; it hardly ever occurs except in patients 
who have already crossed the border line between simple 
nervo-motor dyspepsia and that form of dyspepsia with 
stasis and excessive fermentation which we shall study 
further on. We must recognize the fact, however, that 
this boundary line is a movable and uncertain one, and we 
often see symptoms pointing to stasis and fermentation 
disappear when the causes of dyspepsia have been removed 
and suitable hygienic and medicinal treatment has been 
instituted. 

Permanent dilatation is a possible termination of this 
form of dyspepsia when the causes persist, when the pa- 
tient has insufficient resisting power, and when gastritis 
has become actually established. 

Sufferers from a mild degree of nervo-motor dyspepsia 
usually preserve their appetite, but in the more accentuated 



92 DISEASES OF THE STOMACH AND INTESTINE. 

forms the appetite may disappear and may even, in the 
most severe cases, give place to an actual repugnance to 
food. We sometimes see patients, especially the neuras- 
thenic, fall into an actual condition of inanition and of de- 
cline. They emaciate, lose strength and courage, become 
incapable of any labor, and sometimes even are bedrid- 
den. These cases are fortunately rare; their treatment 
demands the application of the Weir-Mitchell cure, or 
forced feeding. 

Sometimes, as we have said, the intestinal phenomena 
assume a greater importance than the gastric. Constipa- 
tion is obstinate and there is frequently a muco-membra- 
nous enteritis. We shall devote a special chapter to the 
consideration of these phenomena. We may mention here 
only the delayed abdominal pains, veritable colic, coming 
on several hours after eating ; there is a sensation of burn- 
ing and of griping, following the direction of the trans- 
verse colon. These pains are sometimes accompanied by 
exaggerated peristaltic or anti-peristaltic movements which 
are visible on inspection of the abdomen. Sometimes, but 
not alwa} T s, these painful crises are premonitory symptoms 
of intestinal involvement, and we may detect, on palpa- 
tion, signs of temporary or of permanent dilatation of the 
colon or caecum. 

External examination shows the presence of abdominal 
tympanism, sometimes generalized and sometimes limited 
to the stomach or colon. The stomach is distended ; its 
lower limit is not below the normal, but its resonance is 
perceived over a greater area than usual. Sometimes a 
succussion sound may be obtained rather far down, but 
there is no permanent stasis and the stomach empties itself 
completely in the intervals between meals. Nevertheless, 
in cases in which atony predominates we may find all the 
intermediate stages between a distended stomach and a 
stomach actually dilated, such as we shall describe later. 

The giving of a test meal and subsequent examination 
of the gastric juice will show us that the secretion is nor- 
mal in a goodly number of cases ; but in others we may 






NERY0-M0T0R DYSPEPSIA. 93 

find a notable diminution in the quantity of h} T drochloric 
acid. Sometimes even we shall find that the free hydro- 
chloric acid has disappeared and chemical examination 
will show us that there is an actual diminution in the 
amount of combined hydrochloric acid, that is to say, 
there is veritable hypochlorhydria. To arrive at this diag- 
nosis it is sufficient to determine by means of the ethyl- 
green test the absence of free hydrochloric acid at the same 
time that there is a weak total acidity, that is, below 1.60 
per 1,000. In cases of hyperacidity without free hydro- 
chloric acid a more extended chemical examination will be 
necessary. However, the presence of an acid odor, sharp 
and butyric, of the gastric juice, affords a presumption of 
secondary fermentation of the contents of the stomach. 

The main point is that the stomach empties itself well, 
getting rid of its contents completely, although occasionally 
less rapidly than the normal organ. When this occurs 
both time and material are wanting to permit of fermen- 
tation taking place in the stomach to such an extent as to 
become a matter of much importance. 

Let us review rapidly the causes of this morbid state. 
Nervo-motor dyspepsia occurs very frequently in the neu- 
ropathic, in actual neurasthenics, in the gouty, the rheu- 
matic, etc., all belonging more or less strictly to the great 
neuropathic family. It is seen also in the anaemic and the 
chlorotic, who are also neuropathies, in the first stage of 
tuberculosis and in various conditions of chronic poisoning. 

In the neuropathic we often observe the effect of more 
or less active intervening causes, such as disappointments, 
mental emotions, overwork, and the like, or that produced 
by the ingestion of irritating substances, such as insuffi- 
ciently masticated food, dishes too highly spiced, and strong 
liquors, or by overeating. These last-mentioned causes 
are those to which classical authors attribute the origin of 
gastritis, especially of catarrhal gastritis ; but we have 
already given our views on this point and have said that 
the hypothesis of gastritis, even if its presence were dem- 
onstrated, would not prevent us from including under this 



94 DISEASES OF THE STOMACH AND INTESTINE. 

head cases in which the symptoms observed are exactly 
those which we have just enumerated. 

Before entering upon a consideration of the treatment of 
this condition we must repeat that we shall concern our- 
selves solely with the indications furnished by the gastric 
symptoms, reserving our remarks on the management of 
constipation and its complications for the section devoted 
to the treatment of intestinal disorders in general ; this di- 
vision is artificial, but it is necessary to a clear exposition 
of our subject. 

Many different methods of treatment have been em- 
ployed in the case of nervo-motor dyspepsia, and since this 
form is the most common and also the most amenable to 
treatment, the followers of all or nearly all of these methods 
have been able to point to successful results. This is be- 
cause it is necessary in most cases onry to put the patients 
under discipline, to give them good advice as to the fol- 
lowing out of ordinary hygienic measures, in order to 
effect a considerable amelioration of their symptoms. Ex- 
ercise in the open air, the removal of the ordinary causes 
of fatigue or mental disquietude, abstention from over- 
work, and the avoidance of habitual overloading of the 
stomach, usually suffice to restore, temporarily at least, the 
equilibrium between the functional action of the nervous 
system and that of the digestive canal. This form of dys- 
pepsia is often relieved by measures directed against the 
neurasthenia, since it is so frequently dependent upon this 
neurosis. It j^ields readily when the nervous state is not 
too deep-rooted and when it is not complicated by the ex- 
istence of too powerful hereditary influences. 

This explains the success following the application of 
apparently contradictory measures; it explains also the 
reputation of certain cures carried out at mineral spas, the 
waters of which are almost indifferent. Physicians prac- 
tising at these resorts would render even greater services 
to their patients if thej- would but possess themselves more 
fully of the truth of the principles which we have just laid 
down. By paying more attention to diet and to hygiene 



NERV0-M0T011 DYSPEPSIA. 95 

they would obtain more frequent and more lasting cures. 
It is deplorable, for example, that patients of this class are 
often entrusted, as regards their diet, to the mercies of the 
average hotel keeper and to the traditions of the ordinary- 
table d'hote. 

We shall consider first the ordinary form of the disease 
and after that the more severe form. Under the first we 
recognize two varieties, viz., nervo-motor dj 7 spepsia with 
or without a diminished excretion of hydrochloric acid, 
and nervo-motor dyspepsia with a tendency to stasis and 
hyperacidity. We shall point out what are the special 
indications present in these chemical varieties ; but before 
proceeding to that, we shall examine successively the dif- 
ferent modes of intervention which are at our disposal in 
the management of this affection. We may class these as 
follows : 

(a.) Diet. 

(b.) Climatotherapy (including cures at different min- 
eral springs). 

(c.) Special manoeuvres of a physical nature, such as hy- 
drotherapy, massage, gymnastics, electrization, mechani- 
cal support to the abdomen. 

(d) Medication of the gastro-intestinal atony, with its 
subdivisions, excito-motor, excito-secretory, and acid. 

This classification has, like all other classifications, its 
advantages and its disadvantages, but we lay little stress 
upon them, for the classification is of service only in en- 
abling us to introduce a little order in our presentation of 
the subject. We are ready enough to admit the artifi- 
ciality in the distinction between an excito-motor and an 
excito-secretory medication, for example, and we ask no 
one to attach a greater significance to it than we ourselves 
do. The fault lies chiefly in the weakness of the human 
intellect, which is able to grasp questions only as they are 
presented in successive order. 

Ordinary Form. — (a) Diet. — What we have said of 
the necessities of diet in cases of dyspepsia in general is 
applicable to nervo-motor dyspepsia. The regime must be 



96 DISEASES OF THE STOMACH AND INTESTINE. 

more or less strict according to the case. Let us consider 
some of the special indications. 

When there is a feeling of weight in the stomach and 
of uneasiness after eating and heaviness in the head evi- 
dently dependent upon the neuropathic state, it is this neu- 
ropathic condition with which we must especially concern 
ourselves. Thus, in the case of neurasthenic patients, run 
down by excessive work or business cares, it will often be 
sufficient to withdraw the individual from his habitual 
surroundings and send him into the country in a neigh- 
borhood where tranquillity of mind will take the place of 
overwork and anxiety, and where mental repose and physi- 
cal exercise will replace the intellectual overwork, in order 
to obtain a cure of his dyspepsia. In the case of patients 
who habitually live too high, who take too much food or 
food too richly prepared, we must advise a very simple 
table. It is useless to go into further details, after what 
we have said concerning the general alimentary hygiene 
of dyspeptics. 

We must never forget that the intestine plays as great 
a part as the stomach, perhaps even greater, in most cases 
of painful dyspepsia. The gaseous distention is located 
as frequently in the bowel as in the stomach ; and we often 
see constipation, alternating or not with attacks of diar- 
rhoea, muco-membranous enteritis, and hemorrhoids. All 
these symptoms demand at times a special treatment, to a 
consideration of which we shall devote a chapter in this 
volume. We must combat the intestinal atony and cure 
the constipation if we wish to improve the digestion, and 
hygiene is here as important as medication; we should 
endeavor as far as possible to bring about a regular action 
of the bowels without having recourse to drugs, but un- 
fortunately this is not always an easy matter. 

Eggs, meat, fish, and milk products are what these pa- 
tients usually digest the best, and they often of their own 
motion exclude vegetables from their diet. When they 
are simply advised to take vegetables, without any addi- 
tional recommendation, they do not get along very well ; 



NERV0-M0T0R DYSPEPSIA. 97 

the sensations of weight and of gaseous distention of 
which they complain are increased. Some even suffer 
from veritable gastric crises when taking vegetables and 
green fruits. The results of such a diet are even worse 
when there is a tendency to stasis or when the atony of the 
stomach is temporarily increased. If then it is thought 
best to advise the taking of vegetables, and this counsel is 
good in certain cases, they should be told to eat them in 
the form of purees, and all fruit should be cooked. It is 
curious to note that almost all writers, whatever their 
theories of the condition may be, generally give the same 
advice. The vegetarian regime, as formulated by Dujar- 
din-Beaumetz, is especially indicated here; given for a 
certain period, it is of extreme utility, having all the value 
of a " cure. " 

In cases in which constipation is very marked the pa- 
tients may be advantageously counselled to take a grape 
cure or whey cure. It is difficult to estimate how much of 
this advantage is to be attributed to the external adjuncts of 
the cure, such as a sojourn in a picturesque country, prom- 
enades in the open air, and tranquillity of mind. 

Drinks. — The question of drinks is one of great impor- 
tance in the therapeutical management of this form of 
dyspepsia. As a general rule red wine should be forbid- 
den, as that seems to be particularly irritating to the gas- 
tric mucous membrane and to favor organic fermentation. 
We have seen the gastric acidity increase almost imme- 
diately in dyspeptics who had taken wine after having been 
for some time deprived of it. White wine diluted with 
water is frequently prescribed, and it is not a bad drink 
in light cases of dyspepsia. The same is true of a light 
beer or of beer sufficiently diluted with water. But none 
of these is as good as pure water or faintly alkaline natural 
mineral waters not too heavily charged with carbonic acid 
gas ; a too large proportion of carbonic acid would be a 
disadvantage. In general the so-called table waters are 
very suitable for these cases, and their number is sufficient 
to permit of a choice. Certain waters poor in alkaline 
7 



98 DISEASES OF THE STOMACH AND INTESTINE. 

constituents have the advantage of being very pure and 
agreeable to the taste. 

Milk as a beverage is not suited to more than half the 
patients of this class ; it has the disadvantage of leaving a 
taste in the mouth and of diminishing the appetite. We 
shall speak later of kephir, which Hayem recommends 
highly in cases evidently belonging to this category. 

Very often, especially in cases in which flatulence and 
a feeling of weight on the stomach are prominent symp- 
toms, hot drinks taken with the meals are the best; they 
alone in a good number of cases suffice to bring about a 
cure. The patients may take weak tea or a weak grog 
made of raw or burnt brandy or rum; some prefer chamo- 
mile tea or a decoction of orange-flowers, but it makes no 
difference what the decoction is, the object is simply to 
induce them to take hot water and the flavoring may be 
left to the individual taste. Writers are not agreed as to 
the quantity of fluid which is permissible, some advising 
a dry diet, others allowing full liberty as to the amount of 
drink. We usually allow patients taking only hot bever- 
ages to drink at discretion, for they then have no desire to 
drink an excessive amount; indeed, making a person take 
only hot beverages is generally equivalent to making him 
drink less. There are some people who really do drink 
too much, two or three pints with each meal, for example, 
and these must be put upon absolute rations ; instead of 
taking two or three pints at each meal they must content 
themselves with that amount in the twenty-four hours. 

The use of ice must be prohibited, and no very cold 
beverages should be permitted. It may be true that cold 
water will produce contractions of the smooth muscular 
fibres just as hot water does, but this contraction quickly 
yields to a very pronounced relaxation, and, as we have 
seen, one of the principal indications in the treatment of 
nervo-motor d}'spepsia is to combat the tendency to relaxa- 
tion of the smooth muscular fibres of the gastro-intestinal 
tunics. 

Bread. — Only a relatively small amount of bread is al- 



NERVO-MOTOB DYSPEPSIA. 99 

lowable. It is a matter of common observation that the 
ingestion of a large quantity of this article of food fre- 
quently causes a sensation of weight in the stomach and 
of general malaise. As a general rule not more than 100 
grammes (about three ounces) should be taken at each 
meal. The bread must be well cooked, preferably stale, 
and it must be chewed slowly, so as to become thoroughly 
mixed with the saliva. 

We must insist even more firmly upon a strict observ- 
ance of our recommendations when there is a tendency to 
stasis, to hyperacidity, or especially to gastric intolerance. 
Stasis and hyperacidity are often shown subjectively by a 
sensation of burning or even of pain at the pit of the 
stomach. There are acid eructations and sometimes re- 
gurgitations of the contents of the stomach, causing an 
acid and bitter taste in the mouth. This bitterness seems 
to be due, not to the bile, as was formerly supposed, but 
to peptone. Sometimes, but more rarely, there are eruc- 
tations of a fetid character, having the odor of spoiled 
meat or rotten eggs. This may happen even when there 
is no permanent dilatation of the stomach, and when the 
organ does empty itself, tardily perhaps but still completely, 
of its contents. 

Vomiting may take place at longer or shorter intervals. 
It is seldom that this happens after each meal, though it 
may come on at this time and be preceded by severe pain, 
such as is felt in hyperchlorhydria, in simple ulcer, or in 
acute or subacute gastritis. Some people, indeed, have 
an exaggerated excitability of the mucous membrane of 
the stomach, and in them an amount of organic acid which 
would not affect others provokes pain and, by reflex action, 
vomiting. As we have said before, it matters little in 
these cases whether there is or is not present a certain de- 
gree of gastritis. These more serious cases are just on the 
edge of permanent dilatation, but they often recede under 
the influence of a suitable diet and medicinal treatment. 

The regime must be more severe in these cases than in 
those which we have hitherto considered. Wine must be 



100 DISEASES OF THE STOMACH AND INTESTINE. 

absolutely withdrawn at once in all these cases. It will 
be well also to wash out the stomach occasionally. Those 
patients who are willing to submit to this form of treat- 
ment will derive much benefit from the administration of 
meat powder through the stomach tube and from a milk 
diet. Milk alone, if it is well borne, may be useful ; we 
might institute a sort of milk cure at the beginning. After 
that it would be well to give freshly prepared meat powder 
in bouillon, milk soups, rice powder gruel, purees made of 
dry vegetables, eggs, meat finely minced, and finally cold 
roast meat well cut up. We shall find in Leube's table 
gradations which it might be well to folloAV in bringing 
the patient gradually back to a normal diet. We might 
also try kephir, as Hay em recommends. 

(b) Climatotherapy. — The resources of climatotherapy 
are by no means to be despised in these cases, for it is a 
good deal to take patients from their habitual surround- 
ings and place them in new one> where they will live a 
less artificial life and be less overworked mentally. Cli- 
matotherapy is directed more particularly against the 
nervous element in the disease; it includes travelling and 
a sojourn, for a longer or shorter period, in a new place. 
Travelling may be recommended to patients who do not 
suffer too much from hotel life and who can stand table 
d'hote accommodations. The benefit afforded by a life in 
the open air and by a change of scene constitutes very 
largely the advantage of a course at any of the popular 
spas. Physicians practising at these resorts ought to make 
the most of every advantage which the place offers. They 
should not be afraid to lay down minute directions con- 
cerning exercise, promenades, massage, hydrotherapy, 
etc. These nervo-motor dyspeptics, so often neuropathic, 
are the patients who must be disciplined and the physician 
should never hesitate to act with authority. 

(c) Special Manoeuvres of a Physical Nature. — Gym- 
nastics. — Exercise of this nature is especially useful from 
the point of view of general health. It increases the rate 
of metabolism and improves the appetite. It is more par- 



STERV0-M0T0R DYSPEPSIA. 101 

ticularly valuable in the case of dyspeptics who lead a 
sedentary life and do not take sufficient exercise to work 
off by physical labor the excess of nutritive material taken 
into the system. Some of these exercises have, as their 
special object, to overcome the tendency to constipation; 
they are executed as follows : the patient lying on a sofa 
raises himself to a sitting posture without the aid of his 
hands ; then, standing with the back against a wall, he 
bends forward and again straightens up, touching the wall 
with the hands alternately above and below. This is what 
is called Daily's wail exercise. 

Hydrotherapy. — This is a favorite method of treatment 
of dyspepsia among certain physicians. It acts more es- 
pecially in an indirect way, by improving the general 
health and reducing the neuropathic tendencj^. The prin- 
cipal methods of applying this treatment are cold spong- 
ing, the cold pack followed by rubbing, the cold douche in 
the form of shower or continuous jet, the alternating cold 
and hot jet, the Scotch douche, and the hot douche. Cold 
sponging or the cold pack followed by friction may be used 
in the case of neurasthenics and of the ansemic or chlorotic 
who are afraid of the cold douche and who may be gradu- 
ally accustomed to it in this way. The cold douche, espe- 
cially in the form of a continuous jet, is indicated when it 
is desired to tone up weak and debilitated subjects. The 
hot douche is better adapted to those of an excitable dis- 
position with a tendency to insomnia. According to our 
experience, neurasthenics are more often benefited by the 
hot jet douche than by the cold. 

Massage. — We must distinguish here between general 
massage and local massage made with a special object. 
General massage may be useful under certain conditions 
in the same way as hydrotherapy, climatotherapy, or gym- 
nastic exercises. The special object of local massage is to 
combat the atony of the stomach or intestine and to cure 
constipation. 1 

1 Dujardin-Beaumetz : " L'Hygiene Therapeutique, " 2d edition, 
1890. 



102 DISEASES OF THE STOMACH AXD IXTESTINE. 

Electrization. — All forms of electricity have been em- 
ployed, static, faradic, and galvanic. Of course static 
electricity is employed only externally. The patient, seated 
on a chair with glass legs, so as to be completely isolated 
from the floor, is connected with the accumulator of a 
static machine ; then, by means of rods or balls of metal 
connected with the ground by a chain, electric sparks are 
drawn from the epigastric region. The stimulation seems 
to be sufficient to provoke contractions of the stomach; 
and this supposition is rendered all the more probable by 
the fact that the same stimulus applied along the course of 
the large intestine is folloAved in a short time by a move- 
ment of the bowels. 

Galvanization and faradization may be applied external- 
ly or internally. When applied externally one of the poles 
is placed in communication with the skin of the lumbar re- 
gion by means of an electrode made of a large piece of tin 
covered with chamois and wet with a saline solution ; a 
similar electrode of smaller size, connected with the opposite 
pole, is placed over the epigastric region. By using rather 
large electrodes we avoid an electrolytic action when em- 
ploying direct currents. 

For internal electrization various sounds have been con- 
structed, all of which are made upon the same principle. 
The conductor, either a wire or a very flexible metallic 
rod, is inclosed in a stomach tube, and terminates in a 
ball or metallic button within the tube, a short distance from 
its opening extremity. In this way the end of the rheo- 
phore cannot come in contact with the mucous membrane, 
and the electric current can reach it only through the liquid 
contained in the stomach ; we thus avoid all danger of ulcer- 
ation by electrolytic action. The other pole is brought into 
contact with the skin by means of a large flat electrode. "We 
may, by employing this apparatus, apply either galvanic 
or faradic currents. Einhorn has modified this apparatus 
in quite an elegant way. The intragastric electrode con- 
sists of a metallic ball enclosed in a hard rubber capsule 
having many openings ; this capsule serves to prevent di- 



NERVO-MOTOR DYSPEPSIA. 103 

rect contact of the metal with the stomach- wall. The ball 
is connected with the battery by a very fine soft wire en- 
closed in a flexible rubber tube of small calibre, and it is 
introduced into the stomach by the act of swallowing, the 
passage of an oesophageal tube being thus avoided. This 
is called by Einhorn the "deglutable stomach electrode." 1 

The intensity of the continued current may vary between 
10 and 30 milli amperes, but it should always be reduced 
to the lower figure when opening or closing the circuit. 

Electrization of the stomach causes contraction of its 
walls, and is an active means of combating atony and dila- 
tation. Rave's 2 researches show that electrization excites 
the secretion of the gastric juice, whence the conclusion 
follows that, if this measure be useful in nervo-motor dys- 
peptics in whom secretory atOny often accompanies motor 
atony, it is contra-indicated in patients with hyperchlor- 
hydria in whom the secretion should not be increased but 
rather lessened. . Electricity, either galvanic or faradic, 
when externally applied seems actually to reach the stom- 
ach provided we employ electrodes of sufficient size and 
sufficiently moistened; it is certainly easy of application 
and unobjectionable. 

Support to the Abdomen. — The phenomena of nervo- 
motor dyspepsia have been attributed by Glenard 3 to en- 
teroptosis, that is, to a falling down of the mass of in- 
testines insufficiently supported by the abdominal walls. 
This would result in a very marked drawing upon certain 
parts of the mesentery and of the nervous plexuses. There 
is no question but that this prolapse of the intestines as a 
whole does occur in certain cases, as, for example, in women 
who have had many successive pregnancies and in indi- 
viduals who have become emaciated after having previ- 
ously been very corpulent. There is, in such cases, often 
a tendency to veritable pantoptosis, to a sinking down of 

1 The New York Medical Record, May 9th, 1891. 

2 Rave, " Traitement des Dyspepsies par l'Electricite. " These de 
Paris, 1892. 

3 See the chapter on Enteroptosis. 



104 DISEASES OF THE STOMACH AND INTESTINE. 

all the organs suspended in the abdominal cavity. When 
this occurs the application of a well-fitting abdominal 
bandage is productive of great relief. We are in the habit 
of recommending a belt made of three folds of tricot, form- 
ing one plait behind and simply overlapping in front, so 
as to make a broad band, and fastened by safety-pins. 
The advantage of this simple belt is that it may be ap- 
plied very exactly, the three bands being independent of 
each other. The lower band, which has a tendency to slip 
up, ma3' be kept in place by straps passing between the 
thighs or by elastics attached to the stockings. 

Excito-Motor Medication. — Are there any drugs which 
have the special property of stimulating the gastric mus- 
cles to contraction? But few investigations have been 
made as }^et in this direction and the experimental methods 
upon which they have been based are not all of an equal 
value. Klemperer has made some experiments by means of 
the oil test, which consists in giving 1 5< » grammes of oil be- 
fore a test meal ; the food is then ingested together with the 
substances whose action is to be determined, and the stom- 
ach is emj (tied at the end of a given time. The amount 
of oil present in the liquid removed is determined by dis- 
solving it out with ether. The less oil there is remaining 
in the stomach, the more active are supposed to have been 
the gastric movements. The method is certainly not with- 
out its disadvantages, for it is not a very simple matter to 
make the patient ingest 150 grammes of pure oil; and 
furthermore the presence of the oil may, in itself, influ- 
ence the functional activity of the stomach, so that we are 
not working under normal conditions. But however this 
may be, Klemperer holds that alcohol, the bitters, and 
strychnine are stimulants of the gastric movements. The 
excito-motor action of alcohol has been disputed by many 
writers. 

Ewald, basing his conclusions upon the results of the 
salol method of experimentation, has also come to the con- 
clusion that strychnine is an excitant of the gastric move- 
ments. This method is based upon the fact that salol is 



NERV0-M0T0R DYSPEPSIA. 105 

not attacked in the stomach but that, when once it has 
reached the intestine, it is split up by the action of the 
pancreatic juice into salicylic acid and phenol. The sub- 
ject is made to take a dose of 15 to 30 grains of salol, and 
then the urine is examined every fifteen minutes by the 
chloride of iron test, for traces of salicylic acid. This sub- 
stance, when it exists, forms a very marked deep blue color 
with perchloride of iron. The more active the movements 
of the stomach are, the sooner will this reaction appear in 
the urine, but in cases of atony and stasis it will be more 
or less delayed. These conclusions of Ewald have been 
disputed, and it has been held that the significant fact is 
rather the length of time during which the presence of 
salicylic acid may be determined in the urine ; the more 
inefficient were the movements of the stomach, the more 
slowly would this acid be eliminated, and consequently the 
longer would its reaction be obtained in the urine. It has 
even been asserted recently that the phenol resulting from 
the decomposition of salol may be found in the gastric 
juice, and this fact, if true, would render the method 
valueless (Berlin Medical Society, October 29th, 1888). 

Klemperer says that an increase in the acidity of the 
gastric juice does not accelerate the movements of the 
stomach, but that, on the contrary, an excess of hydro- 
chloric acid retards the expulsion of the gastric contents. 
This statement tallies with what we know of hyperchlor- 
hydria with hypersecretion, which is so often accompanied 
by dilatation and stasis. 

Marcone ' says that bitters taken with the food increase 
the quantity of gastric juice and also stimulate the mus- 
cular walls of the stomach to greater activity. 

From our own observation of the results obtained in 
the treatment of flatulent dyspepsia, we have come to re- 
gard ipecac in small dose as one of the best stimulants of 
the muscular coat of the stomach. We may give the 
remedy in powder, in doses of from } to 1| grain after 
each meal. This amount should be given in broken doses 
1 La Riforma Medica, June, 1891. 



106 DISEASES OF THE STOMACH AND INTESTINE. 

at intervals of a half -hour or an hour, in wafers, with or 
without other powders, such as bicarbonate of soda, cin- 
chona, calumba, etc. The drug may also be given in the 
form of the ipecac lozenges of the shops, from two to five 
of which may be taken at intervals after each meal. We 
prefer, however, a mixture of equal parts of the tinctures 
of ipecac, calumba, and gentian, the dose being so propor- 
tioned that the patient receives an amount of the tincture 
equivalent to the above-mentioned quantity of ipecac in 
powder. 

Administered in these doses ipecac ought not to provoke 
nausea, but as individuals vary greatly in their suscepti- 
bility to this action of the drug, it should be given tenta- 
tively at first. It is well to assure the patients that, al- 
though they are taking ipecac, there is no occasion for 
them to suffer from either nausea or vomiting, otherwise 
the simple name may suffice to excite these symptoms in 
them by suggestion. 

In certain cases of neurasthenic d} T spepsia in which there 
was a tendency to stasis, I have sometimes administered 
ipecac in another way. I gave it once every three days 
in dose sufficient to produce a slight degree of nausea and 
moderate salivation. The following day a douche bath 
was administered, and the da} T after that nothing except 
the ordinary alimentary regime; and so on in series of 
three days each. I obtained very good results from this 
practice. 

Ipecac does not act upon the stomach alone, but also 
upon the bowels in such a way as to increase their action, 
this being an additional advantage when constipation ex- 
ists, as it nearly always does in the cases under discussion. 
In order to increase this action still more, tincture of rhu- 
barb may be given at the same time with the tincture of 
ipecac. 

The bitters given in the form of tinctures after meals, 
while digestion is going on, seem often to have an excel- 
lent effect upon the appetite. It would appear also that 
their aperitive action is greater when they are given in 



NERV0-M0T0R DYSPEPSIA. 107 

this way than when they are taken on an empty stomach 
or immediately after meals. 

Excito- Secretory Medication. — With rare exceptions, 
and those among recent writers, the aim of physicians in 
the treatment of dyspepsia has always been to excite the 
secretion of the gastric juice. Leven, however, opposes 
this view, believing that the trouble lies in the presence of 
an undue amount of fluid in the stomach, in gastrorrhcea, 
which he attributes to inflammatory congestion of the gas- 
tric mucous membrane. Hay em, who takes an almost ex- 
clusively chemical view of dyspepsia, lays great stress 
upon hypopepsia, which he finds of frequent occurrence, and 
is therebj- led to attach great importance to whatever will 
excite the secretion of the gastric juice and increase its 
chemical action. We do not attach so much importance 
to a simple diminution of the chemical processes taking 
place in the stomach, but place great dependence upon the 
intestine for supplemeuting the action of the stomach, and 
we therefore think that the great enemy to be combated is 
the motor insufficiency of this organ, whether any lesion 
be present or not. Our aim is, therefore, to tone up the 
general system and to increase the gastric movements. 
Nevertheless, when there is a diminution in the quantity 
of hydrochloric acid secreted by the mucous membrane, 
we think it well to increase the chemical function of the 
stomach, provided we can do so without prejudice to its 
motility. It is not easy, however, to act thus upon one 
independently of the other, and certain motor stimulants 
are at the same time excitants of secretion; these are, 
without doubt, the best agents to employ in the treatment 
of nervo-motor dyspepsia associated with diminished se- 
cretion of hydrochloric acid. 

There are very many substances capable of stimulating 
the flow of gastric juice. Unfortunately many of them 
are dangerous, and many of them are liable to cause gas- 
tritis when too long continued, for the same reason that 
they increase the secretion. Hay em has shown by a num- 
ber of interesting experiments that the primary stimula- 



108 DISEASES OF THE STOMACH AND INTESTINE. 

tion shown in the increased secretion of hydrochloric acid 
is often followed by a secondary period during which a 
diminution or even an actual suppression of this secretion 
takes place. It has not been proven that gastritis is re- 
sponsible for this secondary weakening of the chloro-peptic 
functions of the stomach, yet we cannot be too cautious 
while giving these remedies. We must not push the 
stimulation of the mucous membrane of the stomach too 
far nor follow it up too long. We are prepared, indeed, 
b}" what we have learned of nervo-motor dyspepsia not to 
carry the use of excito-secretory medication to too great 
lengths. 

Alkalies as Excitants of Gastric Secretion. — The least 
dangerous of these is bicarbonate of soda. It has been 
shown by numerous authors that bicarbonate of soda in 
small dose may increase the acid secretion of the stomach. 
The theory of this is that the bicarbonate of soda in com- 
bination with hydrochloric acid is split up into chloride of 
sodium and carbonic acid, both of which substances stimu- 
late the mucous membrane and increase its secretion. 
This theory remains to be confirmed by more careful 
analysis. 

Gilbert has begun a series of experiments in this direc- 
tion, but has not yet completed them. He conducted them 
on a dog having a gastric fistula, the chemical functions 
of whose stomach he had previously determined by Win- 
ter's method. He gave to this dog a one-half per cent 
solution of bicarbonate of soda, which is about the propor- 
tion of this salt contained in Vichy water, sometimes with 
the meat, sometimes before and sometimes after it. When 
the alkaline water was administered at the same time with 
the meat the gastric secretion was not modified, nor was 
it when the water was given a quarter or a half -hour before 
eating. But when it was given an hour before it increased 
the secretion of the gastric juice and the production of hy- 
drochloric acid. When the alkaline water was given to 
the dog after his meal, digestion was retarded. 

The results of these experiments are not entirely satis- 






JfERVO-MOTOR DYSPEPSIA. 109 

factory, and it would be very desirable to ascertain what 
takes place in the human subject under analogous condi' 
tions, and not only in healthy individuals, but also in those 
suffering from the different varieties of dyspepsia. It 
would be well also to ascertain, not only the proportional 
amount of hydrochloric acid, the percentage, but also the 
absolute amount contained in the total quantity of the 
gastric juice, a procedure which, can be carried out in a 
certain number of patients by employing the method de- 
scribed by Remond and myself. 

But since it has been shown that, whatever way it acts, 
bicarbonate of soda, given in small doses on an empty 
stomach, does increase the secretion of hydrochloric acid, 
it would be proper to advise patients suffering from a lack 
of this secretion to take an alkaline water some time before 
meals. We have shown that hot drinks are useful in 
overcoming muscular atony of the stomach, and we may 
fulfil a double indication by giving the alkaline water as 
hot as possible an hour before eating. 

Recently Lemoine and Linossier, as a result of their ob- 
servations on a case of merycism, have asserted that bi- 
carbonate of soda was always, even in large dose, an ex- 
citant of the secretion of hydrochloric acid. This view of 
the action of bicarbonate of soda has never been held by 
any except the authors above mentioned, and it does not at 
all coincide with what we ourselves have seen in cases of 
hyperchlorhydria. Nevertheless, we are willing to admit 
that even in these cases we must not abuse the adminis- 
tration of bicarbonate of soda. 

There are many other excitants of the gastric secretion, 
such as alcohol, many alcoholic tinctures, iodides and bro- 
mides of potassium and of sodium, probably tincture of 
iodine, the chloride and the sulphate of sodium in small 
doses, kephir, the bitters, possibly creosote, which has been 
recommended as a stomachic by Klemperer, spices, and the 
astringent tonics, among which we naturally place con- 
durango. This list might easily be increased by the ad- 
dition of other drugs and of compounded beverages the 



110 



DISEASES OF THE STOMACH AND INTESTINE. 



abuse of which may excite gastritis. The stimulating 
action of drinks of this kind is the more marked since 
they are ordinarily taken before meals, but if taken with 
food their action is much less evident. It is for this rea- 
son that the so-called appetizers (vermouth, absinthe, etc.) 
are more apt to cause dyspepsia than cognac, which is not 
ordinarily taken fasting. Certain medicated wines, rich 
in alcohol and in tannin, like wine of cinchona, are very 
irritating to the stomach. The same is true of iron, naph- 
thol, and many other substances. 

The prolonged use of these remedies usually brings about 
more or less marked exhaustion of secretion and may even 
lead to complete suppression. Certain agents, such as the 
chloride or the sulphate of sodium, seem to stimulate the 
mucous membrane in small doses of 15 to 45 grains and to 
depress the secretion when given in larger doses of GO to 
90 grains. These are facts which we ought not to lose 
sight of, and Hayem, who insists upon this particular 
point, maintains that apepsia is frequent in patients who 
have taken one or more courses of the waters at Carlsbad. 
The Carlsbad treatment is not suited to cases of atony with 
diminished secretion of hydrochloric acid, unless it can be 
proven by clinical observation that the improvement of 
the digestion as a whole is so great as to compensate for 
the diminished chemical functions of the stomach. 

Leven gives moderate doses of certain salts immediately 
before meals; these are chloride of sodium, sulphate of 
sodium, iodide of potassium, phosphate of calcium, or 
phosphate of sodium, in doses of 3 to 5 grains. With the 
exception of the phosphate of calcium, which is a weak 
alkali resembling the carbonate of the same base, these 
salts are undoubtedly excitants of the gastric secretion. 
"If we exceed this dose, giving 15 to 30 grains of any 
of these drugs, we run great risk of producing cramps in 
the stomach and of deranging its functions." l 

We have already spoken of alcohol and have said that, 
from the results of numerous experiments, we may con- 
1 Leven : "Traite des Maladies de l'Estomac," page 424. 



NERV0-M0T0R DYSPEPSIA. Ill 

elude with Boas that this substance in small dose has no 
injurious effect upon digestion. Given before eating it 
stimulates digestion, but we must be very cautious in 
recommending the use of gastric stimulants when the 
patient is fasting. The same caution is necessary in the 
case of the astringent tonics, such as cinchona, tannin, 
and condurango, especially when they are given in the 
form of tinctures. If the use of these agents is thought 
advisable it is much safer to give them after meals when 
they will be diluted by the contents of the stomach. When 
so given their effect upon the appetite is in no way dimin- 
ished, and may even be increased. 

Hayem speaks in the highest terms of kephir, which he 
regards as the best remedy in cases of diminished or ab- 
sent gastric secretion. We have already referred to its 
composition and mode of administration. 

The number of substances capable of exciting the gas- 
tric secretion is not small, but on the contrary very large. 
The difficulty is not in stimulating the secretion, but rather 
in keeping it within bounds, so that we need have no fear 
of causing gastritis or of exhausting the secretory, func- 
tions of the stomach. We must also avoid exciting the 
stomach to increased action by remedies given with an 
aim other than the treatment of dyspepsia, as, for exam- 
ple, by iron in anaemia, by the iodide or the bromide of 
potassium, etc. Naphthol especially is a very dangerous 
drug in this sense. 

In the case of nervo-motor dyspeptics in whom gastro- 
intestinal flatulence was a prominent symptom, we have 
often given with good results a powder composed of 15 
grains of sulphate of sodium and 30 grains each of chloride 
and of bicarbonate of sodium. This is to be taken in a 
glass of water in the morning fasting, or at least a certain 
time, say half an hour, before a meal. The powder may 
also be given during meals dissolved in the table water, 
which should preferably be slightly carbonated. The re- 
sults of the remedy given in this way have often been sat- 
isfactory. But there were several elements which might 



112 DISEASES OF THE STOMACH AND INTESTINE. 

have contributed more or less to this success. In the first 
place the carbonic acid in the table water would excite the 
secretion of hydrochloric acid ; ] and then the patients were 
subjected to the observance of a special regime, a point 
upon the importance of which we cannot insist too 
strongly. We may obtain a successful result with the 
employment of very different methods, provided only that 
there is some rule, some discipline, to which these nervo- 
motor dyspeptics, who are often at the same time neuras- 
thenic, are forced to submit. Both patients and physician 
should be penetrated with this truth. If the discipline of 
diet were better understood and more rigidty practised at 
health resorts, even at those where the waters are chemi- 
cally indifferent, these places would become sanatoria of 
the greatest value for many dyspeptics ; and the results of 
treatment at Bprings the waters of winch are really active 
therapeutically would be vastly better than they are now 
under the existing conditions. 

Acid Medication. — The idea of treating certain forms 
of dyspepsia by strong acids, especially by hydrochloric 
acid, is by no means new. Their employment is in some 
sort traditional in England; and it is from the practice of 
English physicians that Trousseau borrowed the idea. He 
relates in his treatise on Clinical Medicine that he was 
struck on seeing one evening at dinner a neighbor, who 
had travelled in countries where English medicine was 
practised, take from his pocket a little vial containing hy- 
drochloric acid and pour out five or six drops. From his 
conversation with this man he became convinced that this 
practice was of real value in certain cases, and he hastened 
to adopt it, though rather timidly as he gave it in doses 
of only one or two drops after meals. After the move- 
ment in the direction of a chemical examination began in 
France, which has in large measure revolutionized the 
treatment of gastric dyspepsia, hydrochloric acid was given 
to all and indiscriminately. 

1 Jaworski : Deutsche medicinische Wochenschrift, Nos. 36-38, 

1887. 






NERV0-M0T0R DYSPEPSIA. 113 

The examination of the contents of the stomach showed 
that there might be a diminution or even a complete sup- 
pression of the secretion of hydrochloric acid in certain 
varieties of dyspepsia, and nothing seemed more natural 
then than to replace the missing acid by way of the mouth. 
Furthermore it was demonstrated that hydrochloric acid 
plays the role of an antiseptic in the gastric juice, and this 
was another reason for giving it in relatively large quan- 
tities. It was known, before these researches were made y 
that the employment of hydrochloric acid in large doses 
was often productive of good in the forms of dyspepsia 
qualified as acid by reason of the acid eructations which 
were present. 

At a later period Talma gave this acid even in cases of 
round ulcer ; he administered it also in almost all cases of 
dyspepsia, feeling his way, as it were, in order to learn 
how it was tolerated. In this way he came to the knowl- 
edge that certain dyspeptics, especially, he thought, ner- 
vous dyspeptics, have a veritable hyperesthesia as regards 
acids. The fact is true, as other authors have borne wit- 
ness. We have noted on several occasions that some pa- 
tients have an exaggerated sensibility to the action of hy- 
drochloric acid, but this special hyperesthesia in no way 
characterizes nervous dyspepsia. 

In many dyspeptics from one-half to one part per thou- 
sand of hydrochloric acid would be needed to bring the 
proportion up to the normal figures. If now we remember, 
as was shown when speaking of saturation by alkalies, 
that more than 5 litres of liquid, counting food and secre- 
tions, pass through the stomach, we see that from 2 to 
6 grammes of hydrochloric acid would be necessary to 
re-establish the equilibrium. But this is the pure acid, 
and as the officinal acid contains only about one-third 
of its weight of hydrochloric acid, it would be necessary 
to give from 6 to 18 grammes of the officinal acid a day. 
These high figures have never, as far as we know, been 
reached ; but it is now well understood that large doses 
of hydrochloric acid or of other strong acids are much 
8 



114 DISEASES OF THE STOMACH AND INTESTINE. 

better tolerated than one would have supposed a few years 
ago. 

Ewald ' gives from 90 to 100 drops of hydrochloric acid 
in three or four doses at fifteen-minute intervals after 
meals. Rosenheim 2 advises the administration of 6 to 10 
drops of hydrochloric acid in a little water repeated several 
times at intervals of fifteen to thirty minutes after meals. 
The German officinal hydrochloric acid is of 25 per cent 
strength. 

Leube is satisfied with much smaller doses. Riegel 
holds that the dose should vary according to the individual 
case. Boas is partial to small doses because he believes 
that the large doses recommended by Ewald are insuffi- 
cient to provoke digestion in cases in which hydrochloric 
acid is wholly absent from the gastric juice. The truth is 
that this acid combines either with the alkaline salts or 
with the albuminoid substances. In cases in which there 
is free hydrochloric acid, but in insufficient amount, he 
U'iws once or twice while digestion is going on from 15 to 
20 drops of the officinal (25 per cent) acid. When the ob- 
ject is to stimulate digestion he gives the acid from fifteen 
to thirty minutes after eating, and when he desires simply 
to prevent the fermentation of food remaining in the 
stomach the remedy is administered when digestion is not 
going on. 

Bouchard 3 uses a 0.4 per cent solution of strong hydro- 
chloric acid, letting the patient take a few swallows dur- 
ing meals or a wineglassful several times repeated after 
eating. It is especially toward the end of digestion, he 
says, when the secretions are becoming exhausted, that we 
must come to the help of the stomach. As much as a pint 
and a half of the above solution may be given during the 
day between meals. 

Hayem employs a one-per-cent solution, of which he 

1 Boas : " Allgemeine Diagnostik und Therapie der Magenkrank- 
heiten, " p. 248. 

2 "Krankheiten der Speiserohre und des Magens, " page 151. 

3 "Auto-intoxication," p. 197. 






^"ERVO-MOTOE DYSPEPSIA. 115 

gives a tablespoonful in a quarter of a glass of sweetened 
water warm or cold, two or three times a day. In this 
way the patient takes from five to seven minims of strong 
hydrochloric acid in the twenty-four hours. 

Hydrochloric acid is without doubt the most commonly 
employed of all mineral acids at the present day in the 
treatment of dyspepsia, yet the English use a number of 
other strong acids, among which, according to Coutaret, 1 
are the following: Nitric acid (17.44 per cent), sulphuric 
(12.5 per cent), phosphoric (13.8 per cent), nitro-hydro- 
chloric (28 per cent). These acids are taken in doses of 
from 10 to 30 drops after meals in a little water, wine, or 
beer. Of all those mentioned the preference is usually 
given to nitro-hydrochloric acid. 

Basing his ideas upon this practice and also upon cer- 
tain theoretical notions of his own, Coutaret employs what 
he calls " Babelized sulpho-nitric acid " (acide sulfoni- 
trique r obelise). The following are its formula and dose : 

1$ Chemically pure sulphuric acid, . 28 parts. 

Nitric'acid, . . . . . . 8 " 

Alcohol (60 per cent) , . . . . 180 " 

The acids^are added to the alcohol very slowly in a ves- 
sel surrounded by ice, and the mixture is left in an un- 
stoppered flask for fifteen days ; then the flask is closed and 
the preparation is allowed to ripen for ten months before 
being used. It contains sulphonitric acid and a small 
quantity of nitric ether. The author makes a solution for 
use containing four parts of the acid to fifty parts of dis- 
tilled water and gives of this a tablespoonful in a little 
water after meals ; double this quantity may be given if 
desired. Hayem says that he has used this mixture with- 
out any benefit. 

The vegetable acids are seldom employed ; we shall refer 
to lactic acid when we come to the treatment of diarrhoea, 
and have already spoken several times of kephir. 

1 " Comment les Anglais Traitent leur Dyspepsie, " Bulletin 
General de Therapeutique, 1892. 



116 DISEASES OF THE STOMACH AND INTESTINE. 

And now, after having given a resume of the methods 
used by various authors, we may be allowed to present our 
own views. But first, what have chemical researches 
taught us concerning the effect produced by these acids 
upon gastric digestion? In what way do the strong acids, 
and hydrochloric acid in particular, influence the func- 
tional action of the stomach as regards its secretion and 
movements? We must confess that our knowledge con- 
cerning these matters is very slight, as what we have 
learned of the effect of hydrochloric acid has been almost 
wholly derived from the simple statements of the patients. 
Jaworski ' has concluded from the results of experiments 
that the prolonged administration of hydrochloric acid 
might cause the suppression of the secretion of the same 
acid by the stomach. Reichmann and Mintz 2 gave to five 
patients 15 drops of dilute hydrochloric acid three times 
ai intervals of fifteen minutes, beginning one hour after 
each meal. Every ten to sixteen days they gave a test 
meal and made an analysis of the gastric juice. The re- 
sults varied in the different cases; in some there was an 
increase, in others a diminution in the quantity of hydro- 
chloric acid secreted. 

In certain individuals the administration of hydrochloric 
acid increases the movements of Uhe stomach, in others it 
diminishes their force. In cases of hyperchlorhydria with 
hypersecretion bhere is an evident tendency to dilatation of 
the stomach, but it must be admitted that the conditions 
here are peculiar. The exaggerated secretion of hydro- 
chloric acid is continuous, and the irritation to which it 
gives rise may finally lead to exhaustion; and then gastri- 
tis always makes its appearance at some period, either im- 
mediately or after the disease has existed for a longer or 

shorter time. 

What indications are we to deduce from these unsatis- 
factory and often contradictory data? Hydrochloric acid 
is evidently unsuited to cases of hyperchlorhydria, and 



Wiener klinische Wochenschr if t, No. 25, 1891 
Deutsche medicinische Wochenschrift, Nos. 36, 38, 1887. 



NERV0-M0T0R DYSPEPSIA. 117 

should be given onry when there is a diminished secretion 
of this acid, and all patients even of the latter class do not 
need it. We prescribe it for those who have pronounced 
anorexia and a marked tendency to stasis and organic fer- 
mentations. In the case of the first named, even when 
given in the moderate amount of 10 to 20 drops in di- 
vided doses after meals, it increases the appetite and 
seems to improve digestion, diminishing the sensations of 
malaise and of weight. It is for this reason that it is 
employed with advantage in the early stages of tuberculo- 
sis and in the chlorotic. When stasis and fermentation 
are present it may be given in larger quantity, 20 to 40 
drops or more after each meal in divided doses at intervals 
of twenty to thirty minutes ; its administration should be 
intermitted for a time every eight or ten days. 

A small quantity of bitter tincture or of tincture of ipecac 
may be added to the solution of hydrochloric acid. Some 
patients complain that this acid acts upon the teeth and it 
is well therefore to have it taken through a glass tube. 
There can be no doubt that good effects are obtained from 
the remedy given in these conditions. Does it act as a 
mechanical irritant, as an excitant of secretion, or as an 
anti-fermentative? Or does it act by hastening the trans- 
formation of the pepsinogenous substance into pepsin? 
Possibly there is a little of each of these actions. 

In no case, however, does it suffice by itself to re-estab- 
lish the equilibrium ; its employment does not absolve us 
from the necessity of having recourse to everything in the 
way of diet and medication which may diminish the possi- 
ble stasis and excite the weakened motility of the stomach. 
As we have said before, we attach a much greater impor- 
tance, in many cases of dyspepsia, to a vice of motility 
than to one of secretion. 

Digestive Ferments. — Elements passing through the 
digestive tube meet successively : in the saliva, the ptya- 
lin which acts on starchy substances, transforming them 
into dextrin and glucose ; in the gastric juice, the pepsin 
which, in the presence of hydrochloric acid, peptonizes the 



118 DISEASES OF THE STOMACH AXI) INTESTINE. 

nitrogenous materials, and the rennet, which coagulates 
casein; in the intestine the pancreatic juice, which is 
capable of peptonizing albuminoids, of transforming the 
starches into glucose, and of emulsifying the fats. Per- 
haps the intestinal juice has a role similar to that of the 
pancreatic juice; this point has neither been absolutely 
proven nor denied by physiologists. 

It was natural to employ these ferments in the treat- 
ment of dyspepsia as soon as we had learned to isolate 
tin in and to prepare them artificially, or rather to extract 
them. We therefore have in commerce pepsin, papain, 
pancreatin, maltin, etc. 

Let us first take a glance at the principal types of the 
preparations which have for their object to produce an 
artificial peptonization, by means of ferments extracted 
from plants or animals, of the food subtances in the diges- 
tive tube. The animal peptonizing ferments are pepsin 
and pancreatin. 

Pepsin is falling more and more into disuse and justly 
so, for the objections to it are numerous. Artificially pre- 
pared pepsin is certainly much less active than that elab- 
orated by the stomach. Furthermore, tin numerous exper- 
iments of artificial digestion made by means of human 
gastric juice have shown that the pepsin is present in the 
great majority of cases in sufficient quantity; what is 
wanting is the hydrochloric acid, and all thai is necessary 
to obtain a satisfactory digestion in the test-tube with 
otherwise inactive gastric juice is the addition of this 
acid. Another objection to the employment of pepsin is 
the well-demonstrated fact that gastric digestion may be 
very weak, incomplete, or even absent, without any special 
deterioration of the general health or appreciable diminu- 
tion of metabolism. Soulier ' supplies us with a final ar- 
gument against the use of preparations of pepsin when he 
tells us that these preparations are often of bad quality, 
rapidly deteriorate, and are incorrectly compounded, con- 

1 H. Soulier : " Traite de Therapeutique efc de Pharmacologie, " p. 
318. 



NERVO-MOTOR DYSPEPSIA. 119 

taining too much alcohol or glycerin, which is injurious 
to the stomach. 

The same objections may be advanced against pancrea- 
tin, and we may add that it acts well only in an alkaline 
medium. It would be necessary, therefore, to give it with 
a quantity of alkaline salts sufficient to neutralize com- 
pletely the contents of the stomach. The most logical 
method of giving it would be to add it to strongly alka- 
linized meat powder introduced through a stomach tube. 
The only indication for pancreatin would be furnished in 
the case of patients who have, in addition to a diminished 
secretion of hydrochloric acid, a marked reduction in the 
amount of urea excreted through the urine, or of those in 
whom, the quantity of urea being normal or even increased, 
there is a marked tendency to emaciation. 

Reichmann * speaks highly of the good effects of pan- 
creatin in atrophic catarrh of the stomach. He prepares 
it in the following way : he takes a fresh beef pancreas, 
minces it fine, and puts it in a pint of 15 to 20 per cent 
alcohol ; this is kept in a cool place for a day or two and 
then filtered. A small wineglassful of this alcoholic ex- 
tract of pancreatin is taken immediately after eating. 

A peptic ferment has been extracted from certain insec- 
tivorous plants, especially from the Carica papaya (papaw). 
This papain has a very active digestive power in the test- 
tube, but it possesses the same disadvantage as pancreatin 
in that it is more active in an alkaline than in an acid 
medium. 

The attempt has been made to do for the starches what 
pepsin ought to do for the albuminoids, namely, to intro- 
duce into the digestive tube ferments capable of increasing 
the action of ptyalin and of pancreatin. When starchy 
grains begin to germinate there is developed within them 
a ferment capable of bringing about the transformation of 
starch into sugar. If such grains are dried and ground, 
we get a farina containing the diastase necessary for its 
digestion. Thus from barley we obtain maltine and mal- 
1 Deutsche medicinische Wochenschrift, No. 7, 1889. 



120 DISEASES OF THE STOMACH AND INTESTINE. 

tose. The employment of these preparations is very logi- 
cal in certain cases in which starchy foods are not well 
borne. 

Pepsinogenous Substances. — The researches of Corvi- 
sart and of Schiff , confirmed by Leven, have shown that 
certain substances have a property of supplying to the gas- 
tric glands the peptogenous principles which form pepsin 
in the presence of hydrochloric acid. The pepsinogenous 
power of the gastric mucous membrane is exhausted dur- 
ing digestion, and normally a long period of repose is nec- 
essary to restore this function. But if bouillon or dextrin 
be given to an animal under experiment, pepsin is found 
to reappear very rapidly. These substances have, there- 
fore, a real peptogenic action. Some authors treat gastric 
dyspepsia by means of these peptogenous substances. 
Herzen ' advises the taking of a cup of bouillon half an 
hour before meals, and he says that dextrin may be given 
even by enema. Dujardin-Beaumetz gives the following 
formula for an elixir 



R Dextrin, 
Rum, 

Simple syrup 
Water, . 



10 grammes. 
20 
70 
160 



This pepsinogenous medication may be thought of occa- 
sionally in the course of the tentative treatment to which 
we are often reduced in the atonic forms of dyspepsia. 

The possibility of fabricating peptones by artificial di- 
gestion has given rise to the idea that already digested 
nitrogenous substances, requiring only absorption and as- 
similation, might be used in cases of necessity, but unfor- 
tunately the results have not justified the expectations of 
those making the experiment. It has been found that 
peptones are not well borne and readily excite diarrhoea. 
Meat powder, either pure or mixed with diastase, is far 
preferable to peptone. It is uncertain whether the latter is 
useful even in the form of enema. Articifical digestion in 
a test-tube is far from being the same as natural digestion 
1 Revue Medicale de la Suisse Romande, February, 1884. 



XERV0-M0T0R DYSPEPSIA. 121 

in the alimentary canal. It has furthermore been shown 
that peptone is a toxalbumin, and it has been claimed that 
certain accidents, tetany, for example, have been caused 
by the production of a peptone of poor quality in the stom- 
ach of patients with hyperchlorhydria (Bouveret and 
Devic). If that is so we can hardly put much trust in the 
peptones of commerce. 

Conclusions. — We have been led into a rather long di- 
gression & propos of antidyspeptic remedies, a considera- 
tion of which would naturally come in this chapter, and 
we think it advisable therefore to review rapidly the gen- 
eral principles of the treatment of the mild and medium 
forms of dyspepsia in which the nervo-motor element pre- 
dominates. 

These patients are often neuropathic, and hygienic and 
tonic treatment is frequently of as much importance as 
that directed against the dyspepsia itself. The observance 
of mental repose, moderate and progressive physical exer- 
cise, climatotherapy, static electricity, massage, and hy- 
drotherapy are the measures to be employed to this special 
end. We must adapt each of these agents to the indica- 
tions in the individual case, and should not prescribe ex- 
citants, cold douches, for example, for very susceptible 
persons who would do much better with warm douches. 

The diet must be regulated in a general way according 
to the rules laid down in a special section ; it is of very 
great importance and will of itself suffice, in a number of 
cases, to bring about a cure. We cannot too strongly in- 
sist that patients of this class, who are very numerous, 
must before all be subjected to a rigid discipline. They 
must not be allowed to indulge in overeating or in the 
abuse of stimulants, alcoholic beverages, spices, or food 
of too rich a character. The table d'hote, such as it exists 
in mineral spring resorts in France, is deplorable in this 
respect. We have repeated this often enough. A word 
to the wise is sufficient. 

Whether there is or is not in these cases of dyspepsia a 
diminished secretion of hydrochloric acid is of minor im- 



122 DISEASES OF THE STOMACH AND INTESTINE. 

portance, provided only the intestinal digestion is active 
enough to make up for the deficiency of the gastric, so that 
the general condition remains good and the losses of the 
organism do not exceed the receipts. The main point is 
to re-establish the normal gastric movements. For this 
we may have recourse to hot drinks, to ipecac, or to nux 
vomica given after meals. Constipation should be treated 
when present, and we must see that the stomach is not 
overloaded or taxed by the accumulation of indigestible 
matters. The external tonics (hydrotherapy, electricity, 
etc.) also act in a way to overcome the gastro-intestinal 
atony. 

The observance of a strict diet would be the best means 
of preventing gastritis, or of arresting its progress if al- 
ready present. In cases in which there is a diminished 
secretion of hydrochloric acid we may give small doses of 
alkalies an hour before meals, and also pepsinogenous sub- 
stances. 

In the case of those who have a tendency to stasis and 
to excessive fermentation we may give hydrochloric acid 
and may also occasionally wash out the stomach. Hydro- 
chloric acid, with or without the bitters, may also be em- 
ployed in cases of marked and obstinate anorexia. 

By means of the measures above indicated we shall be 
able to prevent these patients becoming the subjects of 
permanent gastric dilatation. 

Severe Forms of Nervo-Motor Dyspepsia. — Bouveret 1 
has noted the occurrence of severe forms of dyspepsia 
among neurasthenics, and we also have seen a few cases 
of this nature ; 2 yet there may be neither permanent dila- 
tation of the stomach nor atrophic gastritis in even very 
severe cases of neurasthenia. 

The local symptoms are hardly more accentuated than 
those which we have noted in the common form. They 
consist in a feeling of weight at the epigastrium, flatu- 

1 "La Neurasthenic, " 2d edition, 1891. 

2 A. Mathieu, " Neurasthenie, " Bibliotheque Charcot- Debove, 
1892. 



NERYO-MOTOR DYSPEPSIA. 123 

lence, belchings, heartburn, constipation, with or without 
muco-membranous colitis, a more or less marked burning 
pain in the stomach, coming on some time after eating, 
and in rare cases vomiting. Nevertheless, the general 
condition is poor, there is emaciation, and the skin is yel- 
low, earthy, and flabby. These patients are insufficiently 
nourished, some by reason of the more or less severe pain 
which follows the ingestion of food, others through want 
of appetite, discouragement, or indifference. They some- 
times arrive at such a state that they can no longer go 
out and have no inclination to leave the bed or the lounge. 
The question may even present itself whether there is not 
latent cancer of the stomach or total atrophy of the glandu- 
lar system of the gastric mucous membrane such as is ob- 
served in progressive pernicious anaemia. 

The Weir-Mitchell treatment renders special service in 
this class of cases. The patient, more frequently a woman, 
is isolated from her family and entrusted to the care of an 
experienced nurse, who should be gentle without being 
weak and whose aim should be to restore gradually the 
patient's confidence in herself. At first the confinement 
to bed is absolute, the loss of exercise being made up by 
massage, which increases metabolism and stimulates the 
vitality of the muscular system. At the beginning of the 
treatment the patient is kept upon an exclusive milk diet, 
but gradually other forms of food are added until an ex- 
cessive amount of food is taken. Finally the patient is 
permitted to leave the bed, then to go out, the massage 
being continued, and thus gradually to resume her ordi- 
nary mode of life. As a rule excellent results are obtained 
from this method of treatment directed against both the 
mental state and the inanition. 

In certain cases of this grave form of dyspepsia we have 
succeeded admirably with gavage, using meat powder, 
milk, and eggs. The forced feeding is accomplished by 
means of the stomach tube. 

By this treatment we break the vicious circle in which 
the patients are moving ; they eat little and lose strength 



12i DISEASES OF THE STOMACH A XI) INTESTINE. 

because they are neuropathic, and their nervous condition 
grows worse as a result of their physical deterioration. 
But as their strength improves in consequence of more 
perfect alimentation they regain courage and take up again 
their normal life. The presence of an actual lesion of the 
stomach, such as more or less generalized destructive gas- 
tritis, is no contra-indication to this method of treatment — 
it only renders its success more doubtful. 

Enteroptosis. — It is proper to speak here of enteroptosis 
and to see how far the theory so admirably stated by F. 
Glenard, of Lyons, is tenable. Let us recall briefly what 
are the main points in this theory. ' The intestine is folded 
upon itself a great number of times so as to be contained 
in the limited space afforded by the abdominal cavity, and 
it is held in place by the mesentery and omentum, in the 
thickness of which true ligaments may be distinguished, 
and also by the muscular bands which form the abdominal 
Avails. Now the gut may be increased in density, as hap- 
pens when its gas has been expelled and its Avails have 
contracted upon themselves; or the abdominal support may 
be relaxed; in either case the intestine, no longer properly 
supported, drags upon its ligaments. The chief of these 
ligaments passes from the right bend of the transverse 
colon to the pylorus and adjacent portion of the greater 
curvature. The colon then in its descent drags upon the 
stomach, and the latter in its turn through the lesser omen- 
tum pulls upon the liver. The kidney is also displaced. 
It is not enteroptosis merely, but rather splanchnoptosis. 
This disturbance of equilibrium of the abdominal viscera 
gives rise to symptoms, some of which correspond very 
nearly with those that we have been studying under the 
name of nervo-motor dyspepsia. The reduced abdominal 
tension would produce the sensation of general feebleness 
and of renal and gastric weakness. The dragging of the 
intestine on its mesenteric ligaments and the lesser omen- 

1 Lyon Medical, 1885. Fereol : Societe Medicale des Hopitaux de 
Paris, 1887-88. Cuilleret : Gazette des Hopitaux, September, 1888. 
Kaplan : These de Paris, 1889. Gourcelot : These de Paris, 1889. 



NERV0-M0T0R DYSPEPSIA. 125 

turn would provoke sensations of weight, of emptiness and 
of false hunger. If to these we add the concomitant symp- 
toms due to gastric atony, that is to say, flatulence, acidity, 
a burning feeling, vomiting, pressure, and gastric cramps, 
we shall obtain a general picture of the gastro-intestinal 
dyspepsia of the neurasthenic. 

These patients are relieved at once by an abdominal 
band which raises and supports the intestinal mass. The 
use of this abdominal support, laxatives, a meat diet, and 
alkalies bring about a cure, and that confirms the diag- 
nosis. 

There is much truth in this notion of enteroptosis, and 
it is undoubtedly present in many cases. It is observed 
especially in women who have gone through many preg- 
nancies, and in individuals who were once obese but who 
have emaciated rapidly. It is true also that a want of 
tone and relaxation of the abdominal walls favors the oc- 
currence of constipation and the appearance of the symp- 
toms of atonic gastro-intestinal dyspepsia. These patients 
find great relief from the application of a snug and well 
adjusted abdominal girdle which does mechanically what 
the weakened abdominal walls are no longer able to do. 

Movable Kidney. — A falling down of the kidney, ne- 
phroptosis, is frequently met with in these conditions. I 
do not think, however, basing my judgment upon the ob- 
servation of a rather large number of cases, that the mere 
discovery of a movable kidney should lead to a diagnosis 
of enteroptosis. This condition, especially when the right 
kidney is affected, is not particularly uncommon in wo- 
men; I have seen it in young women in whom there was 
no appreciable relaxation of the abdominal walls, and have 
noted its occurrence in women who have had but one 
child, and even in those who have never been pregnant. 
Others have made the same assertion as to the relation of 
movable kidney and pregnancy. 

It would seem as though the displaced kidney, dragging 
upon the nerve filaments, irritated the nervous system and 
disturbed more particularly the equilibrium of the abdom- 



126 DISEASES OF THE STOMACH VXD INTESTINE. 

inal sympathetic system. In consequence of this, in those 
already predisposed we would see general neurasthenia, 
and, more frequently and more directly, nervo-motor dys- 
pepsia. It is seldom that neurasthenics with movable 
kidney do not present marked symptoms of dyspepsia. 
Their dyspepsia may assume any of the different forms of 
the disease, nervo-motor dyspepsia, hyperchlorhydria, or 
permanent dilatation of the stomach. The most common 
form is nervo-motor dyspepsia, the treatment of which we 
have just discussed. This view is in accord with the 
opinions of most writers on the subject J (Lindner, Landau, 
Sulzer, etc.). 

Patients with movable kidney frequently suffer from 
attacks of vomiting or even true gastric crises. We shall 
speak of the latter in a subsequent chapter, and shall con- 
cern ourselves here only with the special therapeutical in- 
dications resulting from the presence of a movable kidney 
in the subjects of dyspepsia. 

Dyspeptic attacks in persons having a movable kidney 
come on usually as the result of one of three different con- 
ditions, viz., overwork, mental disturbance, and menstrua- 
tion. We must, as far as possible, remove the patient 
from the influence of the first two causes. 

Walking or standing often suffices to maintain or to 
bring back an attack which has been excited by fatigue. 
The patient should rest as much as possible in bed, and 
this, joined with a proper diet, often brings about a notable 1 
improvement. When they are up and walking about they 
should wear a belt provided with a cushion or pad of spe- 
cial construction, designed to keep the kidney in place, or 
at least to support it. When this is insufficient, or when 
the symptoms are really grave, we must consider the ad- 
visability of surgical intervention. Nephrorrhaphy gives 
good results in about fifty per cent of the cases. 

It is not uncommon to find a kidney, the right especially, 
only very slightly displaced. Its lower extremity may be 
recognized on palpation, but its range of descent is very 
1 Lindner : " Ueber die Wanderniere der Frauen. " 



KERY0-M0T0R DYSPEPSIA. 127 

limited. When there is no appreciable relaxation of the 
abdominal walls, the advantage of wearing a belt in such 
cases is extremely doubtful. We must then content our- 
selves, and this recommendation applies to all cases, with 
reducing, as far as the patient will permit it, the evil re- 
sults of constriction by the corset. 



CHAPTER III. 
DILATATION OF THE STOMACH WITH PERMANENT STASIS. 

Bouchard says that every stomach which does not re- 
tract when it is empty is a dilated stomach, but this defini- 
tion is incomplete, for a stomach may be distended with 
gas so as not to contract — that is not a dilated but rather 
a distended stomach. The most important fact, that from 
which all the evil consequences of a dilated stomach flow, 
is that there is a retention of liquids and food particles. 
Every stomach which does not empty itself is a dilated 
stomach — that is a correct definition. The characteristic 
fact about true dilatation, that is to say dilatation with 
stasis, is that the organ is not completely empty in the 
morning at the end of the longest interval between two 
meals. In accepting this as the true definition of the con- 
dition which we are discussing, we eliminate from the 
category of dilatation a large number of cases which beloug 
rather to the class of nervo-motor dyspepsia with atony, 
and we thus restrict very greatly the number of cases of 
true dilatation. 

After making this elimination we still find ourselves in 
the presence of various unrelated conditions which might 
well be surprised to find themselves grouped together in 
the same morbid series. Dilatation of the stomach, even 
with the restrictions that we have made, is not a primary 
disease but rather a secondary morbid condition. It is 
the expression of a number of anatomical and physiologi- 
cal states which differ greatly one from the other, and 
which it is important to distinguish. We may recognize 
the following varieties : 

1. Atonic dilatation, either temporary or definitive. 

128 



DILATATION OF THE STOMACH. 129 

2. Hypersecretion with hyperchlorhydria and permanent 
stasis. 

3. Mechanical dilatation dependent upon some lesion of 
the walls of the stomach or upon pyloric obstruction. 

1. Atonic Dilatation, Temporary or Permanent. — 
Nervo-motor dyspepsia, left untreated or uninfluenced by 
unfavorable conditions of diet or hygiene, has a tendency 
to pass into permanent dilatation. The food is not ex- 
pelled promptly from the stomach and remains there all 
through the interval between meals, at first between the 
morning and evening repast and later all night as well. 
In the early stages there is a curable relaxation of the 
stomach. Medicinal treatment, a suitable diet, and an oc- 
casional washing out of the stomach are often sufficient to 
effect the disappearance of the stasis and its consequences 
for a longer or shorter period. 

In some cases we find that the liquid contained in the 
stomach, especially in the morning, is colored by, if not 
entirely made up of, bile. This reflux has been attributed 
to a permanent incontinence of the pyloric orifice. 

2. Hypersecretion with Hyperchlorhydria and Perma- 
nent Stasis. — We need not return to this form of dyspep- 
sia, to the consideration of which we have already devoted 
an entire chapter. We would only remark that it is prob- 
able that, in the natural course of the disease itself, the 
hyperchlorhydria may disappear and leave behind it a per- 
manent dilatation, with or without simple hypersecretion. 
This would be the consequence of gastritis, whether we 
regard the latter as primary, in accordance with the Ger- 
man theory of acid catarrh, or secondary and consecutive 
to hypersecretion and atonic retention of material in the 
stomach. 

3. Mechanical Dilatation Dependent upon some Le- 
sion of the Walls of the Stomach or upon Pyloric Ob- 
struction. — When there exists a lesion of the stomach 
wall, a degeneration or destruction of the muscular tunics 
by some anatomical process, the organ tends naturally to 
become converted into an inert sac more and more deprived 



130 DISEASES OF THE STOMACH AND INTESTINE. 

of contractility and even of elasticity. This is the out- 
come of all intense forms of chronic gastritis, especially of 
those forms which are accompanied hy a slight degree of 
sclerosis. "When the last-named process is the predomi- 
nating lesion the condition is apt to be the reverse of this, 
the stomach being considerably contracted and markedly 
diminished in calibre (plastic linitis of Brinton). 

Any lesion of the pylorus which narrows its orifice, or 
any tumor in the vicinity which compresses it, becomes, 
by a mechanism easily understood, a cause of extreme 
permanent dilatation. The narrowing and the compres- 
sion of the pylorus may be brought about by a number of 
dissimilar causes, the most frequent of which are cancer 
and ulcer. The mere presence of an ulcer at the pylorus 
may lead to dilatation of the stomach, or the latter may 
result from the stricture caused by the cicatrization of the 
lesion. 

These mechanical varieties of dilatation are the ones 
which usually assume the greatest proportions. Never- 
theless we sometimes see stomachs of enormous size, filling 
up half of the abdominal cavity and extending down even 
to the pubis, in which examination, by the naked eye at 
least, show r a us no sufficient cause for the ectasia. 

Let us now Bee what are the pathological symptoms and 
the possible consequences of this advanced degree of gas- 
trectasia. The symptoms are most characteristic in those 
cases in which there is a narrowing of the pyloric orifice. 
The patients may have in the region of the stomach a 
sensation of mere weight, more or less uncomfortable it is 
true, or of actual pain. The pain is never absent when 
there is an uncicatrized ulcer, and it is usually but not 
always present when there is a carcinomatous lesion at or 
near the pylorus. Quite frequently there are acid eructa- 
tions and pyrosis, but what is especially characteristic is 
the vomiting and the way in which it is produced. 

This vomiting occurs only at intervals of two or three 
days and is then very copious. The patients reject whole 
basinfuls of a liquid frequently containing particles of un- 



DILATATION OF THE STOMACH. 131 

digested food. In these matters may be seen food which 
has been taken perhaps several days before, as for example 
peas, beans, or particles of other vegetables of a nature to 
be easily recognized. When the patients are on a milk 
diet we often see clots of curdled casein. The ejected 
matters have a more or less disagreeable odor, especially 
if wine has not been excluded from the dietary ; sometimes 
a sour butyric odor predominates. Rather commonly there 
is a more or less thick stringy mucus present, and some- 
times we see traces of blood. The vomiting of black blood 
is a sign especially of cancer, that of red blood of ulcer. 
The symptoms are the same when the stricture is seated in 
the duodenum, but when it is located below the entrance 
of the common bile duct the bile flows back in abundance 
into the stomach. This is a rare symptom but one of ex- 
treme gravity, as we may well understand. 

When vomiting does not occur spontaneously the intro- 
duction of the stomach tube in the morning brings out a 
considerable quantity of liquid and solid material such as 
we have just been describing. 

This is what takes place clinically in cases of marked 
dilatation of the stomach caused by obstruction of the py- 
lorus, by extensive lesions of the stomach wall, and, in 
certain rare instances, by advanced atony. The picture is 
somewhat different in cases of hyperchlorhydria and in 
paroxysmal atonic dilatation. Patients with hypersecre- 
tion of hydrochloric acid suffer from delayed pains coming 
on three, four, or five hours after eating. These pains 
wake them in the night and end in an attack of vomiting. 
The patients know so well that vomiting relieves the pain 
that they often provoke it artificially. The ejected ma- 
terial is stringy, glairy, usually slightly colored and of an 
acid odor, which is specially marked when wine has been 
taken. A thick yellowish deposit, made up of the remains 
of starchy food and of softened, undigested bread, collects 
at the bottom of the basin. Sometimes in consequence of 
the presence of bile the material has a bluish color. This 
copious vomiting of a greenish-blue matter is characteristic. 



132 DISEASES OF THE STOMACH AND INTESTINE. 

Some patients, suffering from nervomotor dyspepsia 
with very pronounced gastric atony, have veritable par- 
oxysms of dilatation. Others suffer from permanent stasis, 
with or without vomiting, as a result of some disappoint- 
ment, prolonged mental anxiety, overwork, poor hygienic 
conditions, or of a diet unsuited to the condition of their 
stomach. This occurs also in various cachectic states, as 
in tuberculosis, anaemia, Addison's disease, chronic ma- 
laria, etc. These patients have heartburn, acid eructa- 
tions, a tongue coated or red as if peeled, an acid taste in 
the mouth, a distaste for food, and for meat in particular. 
This marked distaste for food, combined with the cachexia, 
may lead to an error in diagnosis, especially in the more 
severe cases, when cancer of the stomach may be suspected. 

In cases of marked dilatation, especially when vomiting 
is frequent, very obstinate constipation ma}- be present. 
Sometimes there is diarrhoea caused either by a copious 
outpouring of fluid into the intestine, or by the discharge 
into the latter of the contents of the stomach. 

Inspection of the abdomen is often of service in forming 
a diagnosis, and digital or total succussion may give us 
unequivocal signs of gastrectasia. In doubtful cases the 
passage of the sound and lavage of the stomach will decide 
the question as to whether the succussion sound is located 
in the stomach or in the colon. The method of making 
the patient take a large glass of water and then of listen- 
ing for the succussion sound shows merely that atony and 
relaxation of the stomach exist, and is no proof of perma- 
nent dilatation. Sometimes, especially in < ases of pyloric 
obstruction, we may note a projection of the abdominal 
walls corresponding to the dilated stomach, and we may 
even see the movements due to the peristaltic contractions 
of the organ in its effort to overcome the obstacle. Palpa- 
tion will reveal the presence of an epigastric tumor if it 
exists. In doubtful cases we must not omit a systematic 
search for a displaced kidney. 

To what extent is a patient with extreme dilatation poi- 
soned by the toxic substances formed in his own stomach? 



DILATATION OF THE STOMACH. 133 

How important a role does auto-intoxication play in the 
causation of his symptoms? We know that Bouchard at- 
tributed a very great importance to these auto-intoxica- 
tions, and he ascribed to their influence an almost infinite 
number of ills of various kinds, which we shall try to 
enumerate. 

On the side of the liver we have congestion, and as a 
result of this a movable kidney displaced by the enlarged 
liver ; on the side of the nervous system neuralgias, head- 
ache, cerebral weight, melancholy, insomnia, nightmare, 
vertigo, giddiness, and disorders of vision ; on the side of 
the skin various eruptions; on the side of the respiratory 
organs, bronchitis, asthma, repeated attacks of coryza, and 
chronic pharyngitis; and on the side of the kidneys albu- 
minuria or peptonuria. We see that the most prominent 
symptoms in this enumeration are those which may be 
attributed to neurasthenia and to arthritism, another form 
of hereditary neuropathy. A curious fact, and one of great 
importance in this connection, is that none of these symp- 
toms, especially of the neuropathic class, is met with in 
cases of extreme dilatation of the stomach, of dilatation 
from mechanical obstruction at the pylorus (Charcot). 
Patients who have these symptoms are those on the border- 
land between motor atony and dilatation; a condition 
which is curable in the early stages but incurable later, 
when the muscle has been definitely stretched and when 
lesions due to gastritis have become established. 

But does that mean that auto-intoxication has no influ- 
ence in cases of dilatation of the stomach? Not at all. It 
is very probable that it contributes to the production of 
cachexia, which could not be accounted for by inanition 
alone. It explains without doubt the frequency in patients 
with dilatation of a sort of a chronic or recurrent indiges- 
tion as manifested by the anorexia and the unhealthy state 
of the upper digestive tract. 

We must endeavor to restrict or suppress, if possible, 
the secondary fermentation which takes place in the ma- 
terial retained in the stomach. This fermentation is, in 



134 DISEASES OF THE STOMACH AND INTESTINE. 

any event, likely to cause local irritation, to produce gas- 
tritis, or to lead to a diminution in the secretion of hydro- 
chloric acid and to incurable dilatation. 

In considering the prognosis of this condition, we must 
examine successively and separately the different types 
grouped under the common term dilatation. 

Cases of mechanical dilatation, due to lesion of the py- 
lorus, can be relieved only by surgical operation removing 
or turning aside the obstacle. The chances of final cure 
are of course infinitely better when the lesion is a cicatri- 
cial one than when it is cancerous. Extreme gastrectasia, 
due to incurable atony or to degenerative lesions of the 
muscular tunics of the stomach, is almost as grave as can- 
cer of the pylorus ; we have not even the resource, which 
we have in pyloric stenosis, of gastroenterostomy. There 
is nevertheless no actual contra-indication to a trial of this 
operation, even when there is no mechanical narrowing of 
the pylorus. 

The condition of patients suffering from hypersecretion 
of hydrochloric acid with permanent gastric stasis is by 
no means reassuring. It has never yet been demonstrated 
that hyperchlorhvdria of such an advanced degree is cur- 
able. These patients have to fear simple ulcer with all its 
consequences, mechanical dilatation with vomiting, and 
exhaustion from actual starvation. It is true that we have 
not been able to recognize this morbid condition for a long 
enough time to enable us to formulate anything definite as 
to its prognosis, and it is possible that a transformation of 
this affection into simple gastrorrhcea without hyperchlor- 
hydria may be consistent with a very long life. We be- 
lieve that we have seen cases of this kind. 

Atonic neurasthenic dyspepsia terminates occasionally, 
though very rarely, in permanent dilatation. But by 
means of an appropriate diet, of medicinal treatment, and 
especially of gavage, we may often bring back these pa- 
tients to a state of simple nervo-motor dyspepsia. A con- 
siderable amelioration not infrequently follows a few repe- 
titions of lavage, as a result of which we may see the 



DILATATION OF THE STOMACH. 135 

stomach empty itself completely during the night, and its 
acidity, which had been more or less increased by the fer- 
mentation, return to the normal. In some of these cases 
there seems to be almost a resurrection, and patients have 
been cured whom everything appeared to condemn and in 
whom the diagnosis of cancer of the stomach was almost 
certain. 

The treatment, although proceeding along the same gen- 
eral lines, will differ according to the clinical types that 
we have distinguished. In all cases, however, we must: 

1. Reduce as far as possible the bulk of the food ingested. 

2. Prescribe a dietary of such a nature that there will 
be the least possible chance for fermentations. 

3. Assure, as far as we can, the passage of the food from 
the stomach into the duodenum in such a way as to permit 
always of the patient receiving sufficient nourishment. 

4. Practise gastric antisepsis. 

5. Combat the chemical dyspepsia. 

6. Treat the constipation. 

We shall see how to obtain these ends in examining 
seriatim the indications above formulated. 

1. Reduction of the Bulk of the Food. — We must in 
these cases above all give food of great nutritive power, as 
finely divided as possible so that its admixture with the 
gastric juice may be most intimate and so that the amount 
of non-utilizable residuum may be reduced to a minimum. 
Milk, meat powder, and the farinas are especially to be 
recommended. The patients should take but a moderate 
quantity of fluid. 

In cases of mechanical narrowing of the pylorus attended 
with uncontrollable vomiting it is well to give a certain 
quantity of water by enema. We may in this way bring 
about the absorption of from nine to twelve ounces of wa- 
ter in two or three divided doses. 

When, in spite of this, a certain amount of gastric stasis 
persists, we must remove the residue mechanically by 
washing out the stomach. This lavage will have the ad- 
vantage of lessening the tax upon the stomach and of 



136 DISEASES OF THE STOMACH AND INTESTINE. 

withdrawing the mucous membrane from the irritating 
contact of alimentary substances in process of fermenta- 
tion. In cases of hypersecretion it has been advised to 
wash out the stomach in the evening at bedtime. This 
Avould give the organ a period of rest during the night and 
the mucous membrane would be spared for some hours the 
contact of an irritating liquid. Fearing that lavage might 
be an occasion of fatigue or of excitation for the stomach 
I have occasionally, especially in cases of hypersecretion, 
evacuated the stagnating liquid once a day, actually wash- 
ing out the stomach onty two or three times a week. In 
the case of patients who have become habituated to the 
use of the tube, this evacuation is easily accomplished; 
they have only to cough after the tube has been introduced 
in order to charge the siphon and empty the stomach 
without fatigue. After the tube has been introduced, we 
may take advantage of its presence to give meat powder, 
milk, or eggs, if this seems desirable. 

In atonic dyspeptics in whom the stasis has not existed 
Long and is not very pronounced, a few repetitions of the 
lavage will usually suffice to cure the stasis and at the 
same time to effect the disappearance of the organic acid- 
ity resulting from it. There are, as we have said, all 
grades between simple distention from nervo-motor atony 
and dilatation with permanent stasis and organic hyper- 
acidity. 

It is in this class of patients especially that the diet lists 
gotten up by various authors for cases of dilatation of the 
stomach will be found useful. Bouchard's dry diet de- 
serves special mention. He gives two meals a day sepa- 
rated by an interval of nine hours, although occasionally 
he is obliged to permit a third meal. In this case the two 
principal meals are separated b} T an interval of seven hours, 
the bite in the morning preceding the larger meal by four 
hours. He allows but 375 grammes of liquid at each of 
the larger meals, that is to say, a pint and a half a day, 
no liquid being permitted at the smaller meal in the morn- 
ing. The food should not be too fat, well-cooked meat or 



DILATATION OF THE STOMACH. 137 

boiled fish being given by preference. The patient should 
be restricted in his consumption of substances which are 
susceptible to fermentation, taking little sugar, and no al- 
cohol or vinegar. Red wine is forbidden, only white wine 
or beer largely diluted with water being permitted. 

Bread should be eaten sparingly, and what is taken 
should by preference be toasted so as to destroy any yeast 
spores which may have survived the baking of the bread 
in the first instance. For the first breakfast the patient 
may take a boiled egg and some stewed fruit or marma- 
lade, but no bread or liquid. 

The following articles may be taken at the second meal: 
Cold meats, rather well done; hot meat, but stewed in 
preference to rare roasts ; boiled fish ; soft boiled eggs, eggs 
in milk ; milk preparations in more or less solid form ; rice 
in milk, bouillon, or meat juice; vegetable purees, which 
are wrongly thought to increase flatulent dyspepsia; 
cheese, and stewed fruit. 1 

The pint and a half of liquid which Bouchard allows is 
not sufficient for all patients. It is much better, we think, 
to order only hot drinks; the patients are not tempted then 
to drink so much as they are when cold beverages are per- 
mitted, and the heat has the useful property of stimulating 
the smooth muscular fibres of the stomach walls to con- 
traction. 

The following is the diet list drawn up by Rosenheim 
for cases of dilatation of the stomach. He is, as this 
shows, in favor of small but frequent meals : 

6 o'clock — 100 gm. of tea, 50 gm. of bread, one.egg. 

9 o'clock — 100 gm. of meat jelly, 50 gm. of biscuit, 10 gm. of butter, 

a small glass of sherry. 
Noon — 150 gm. of beefsteak, 100 gm. of well- cooked rice, or some 

other vegetable, 150 gm. of red wine. 
3 o'clock — 50 gm. of white bread, 200 gm. of milk. 
6 o'clock — 100 gm. of white bread, 50 gm. of cooked smoked meat, 

20 gm. of butter, 100 gm. of red wine. 
9 o'clock — 100 gm. of tea, 100 gm. of biscuit. 

^'Lecons sur les Auto- intoxications dans les Maladies," p. 189 
et seq. 



138 DISEASES OF THE STOMACH AXD INTESTINE. 

This diet, in our opinion, is better suited to neuras- 
thenics with atonic dyspepsia than to cases of dilatation 
properly speaking. It is less necessary to adhere to the 
strict letter of this dietary than to follow the general prin- 
ciple of small meals composed in such a way as to preserve 
the proper ration of maintenance. The red wine might be 
advantageously replaced by white wine or light beer, or 
by hot drinks, weak grog, etc. We must not forget that 
some persons are not affected pleasantly by tea in the even- 
ing, as it is liable to keep them awake. 

2. The Giving of Food which is Least Liable to Un- 
dergo Fermentation. — This end is attained by a dietary 
such as we have just mentioned. (See the sections on Diet 
and Gastro-intestinal Antisepsis). 

3. To Secure the Passage of the Food from the Stom- 
ach into the Duodenum. — This can be effected medically 
in only one way, viz., by increasing the force of the mus- 
cular contractions of the stomach. We must resort for 
this purpose to some of the agents which we enumerated 
above in the chapter on nervo-motor dyspepsia, such as 
ipecac, tincture of nux vomica, electricity, massage, hy- 
drotherapy, etc. We can hope for success, of course, 
only in those cases in which there is no mechanical ob- 
struction at the pylorus, or in which the muscular wall of 
the stomach is not too extensively involved in the lesion 
or thinned by the long-continued distention. When 
there is a diffuse lesion of the walls of the stomach the 
merely palliative measures, diet and lavage, may be of 
some use. In the case of an organic lesion of the pylorus 
there is still one resource — surgical intervention. This is 
only palliative in the case of cancer, but may be actually 
curative when there is a simple fibrous contraction of this 
orifice. 1 We cannot stop here to speak of the surgical 
treatment of stenosis of the pjdorus, and must content our- 
selves with a word or two concerning the different methods 
employed and their indications. 

1 A. Gurnard : " Traitement Chirurgical du Cancer de l'Estomac.* 



DILATATION OF THE STOMACH. 139 

In order to have any hope of success in operation for 
cancer of the stomach we must perform it early while the 
lesion is still very limited and before any secondary adeno- 
pathy has appeared. Unfortunately a diagnosis at this 
stage is hardly possible, and when the tumor can be made 
out it is so extensive that its removal by pylorectomy is a 
difficult matter ; the operation is then more dangerous in 
itself and its results are very problematical. A return of 
the disease occurs in general at the end of some weeks or 
months, and the patient has then been exposed to the very 
real dangers of a grave operation without adequate com- 
pensation. 

Gastroenterostomy, that is to say the establishment of 
an artificial communication between the stomach and the 
intestine, passing by the obstruction, gives much more 
satisfactory results. The pain is relieved, the vomiting 
ceases, feeding again becomes possible, and the patient 
regains his strength; there seems even to be a period of 
arrest in the progress of the disease. Nevertheless the 
latter continues its evolution, and although the patient 
does not succumb to the results of an obliteration of the 
pylorus, he does perish in consequence of the ravages of 
the cancer. 

The results of operation are much more favorable when 
the stenosis is fibrous and non-malignant in character. In 
such cases dilatation with or without opening of the stom- 
ach, pylorectomy, and also gastroenterostomy have been 
performed. The latter is the operation to be preferred ; it 
is the most easily performed and is attended with fewer 
dangers during and after the operation. The clearest in- 
dication for surgical intervention is offered by pyloric 
stenosis with dilatation of the stomach, occurring as a 
consequence of the cicatrization of a simple ulcer. 

4. Antisepsis of the Stomach.— One indication which 
must be met in dilatation of the stomach is the restriction 
of intra-gastric fermentation. Several of the procedures 
which we have already mentioned have as a secondary 
consequence a diminution of the fermentative processes 



140 DISEASES OF THE STOMACH AND INTESTINE. 

and prevention of auto-intoxication. Among these are 
the reduction in the quantity of the food, the elimination 
of all that might not be digested and thus remain in the 
stomach, the proscription of substances already fermented 
or which are eminently putrescible, the removal of the 
stagnating material by the tube, and finally lavage. Me- 
dicinal antisepsis will be treated of by itself in a subse- 
quent chapter. 

5. Management of the Chemical Dyspepsia. — The 
chemical state of the dilated stomach varies in the differ- 
ent cases. In some there is hyperchlorhydria with hyper- 
secretion, and in others a diminution in the amount of 
hydrochloric acid with or without the acidity resulting 
from fermentation. When there is excessive secretion of 
hydrochloric acid we must, of course, meet the primary 
indications of this variety of dyspepsia, viz., diminution 
of the gastric irritation to a minimum, neutralization of 
the excess of acid by alkalies in large dose, etc. 

In cases of reduced secretion of hydrochloric acid, should 
we try to stimulate the mucous membrane to more abun- 
dant secretion, or to replace the missing acid artificially? 
We may note in passing that the means employed to tone 
up the muscle stimulate at the same time the glands of the 
mucous membrane. Hydrochloric acid is not of much use 
in cases of cancerous narrowing of the pylorus with con- 
secutive dilatation of the stomach, and may well be dis- 
pensed with; indeed, there is reason to believe that we 
shall do better by alkalinizing the contents of the stomach 
so as to suppress the digestive process in the stomach en- 
tirely. Indeed, it happens almost constantly that the epi- 
gastric pains are relieved by the operation of gastroenter- 
ostomy, which is doubtless to be explained by the fact that 
the current of the gastric juice is turned away so as not to 
come in contact with the ulcerated surfaces. It might be 
advisable to endeavor to bring about the same result in 
cancer, when the pains are troublesome, by the adminis- 
tration of alkalies in large doses. Indeed, we have done 
this occasionally with advantage. We ought also to avoid 



DILATATION OF THE STOMACH. 141 

giving hydrochloric acid when there is any suspicion of 
an uncicatrized ulcer. 

The principal indication for hydrochloric acid is inter- 
mittent atonic dilatation, especially when there is exces- 
sive fermentation with organic hyperacidity. Fifteen or 
twenty drops may be given in two or three divided doses, 
or one or two wineglassfuls of a 0.4 per cent solution may 
be prescribed one and two hours after meals. 

6. Treatment of the Constipation. — Patients with 
dilatation suffer almost always from constipation, result- 
ing probably from the fact that an insufficient quantity of 
water reaches the intestine. This condition should be 
treated chiefly in a mechanical way, by means of supposi- 
tories, enemata, massage, and electricity. We should 
avoid putting into the stomach purgative remedies which 
would simply be retained there and fail of the desired 
effect, while adding to the amount of stagnating material 
in this already overburdened organ. 



CHAPTER IV. 

TREATMENT OF THE PAINFUL PHENOMENA IN DISEASES 
OF THE STOMACH AND INTESTINE.— TREATMENT OF 
THE GASTRIC AND INTESTINAL CRISES. 

The principal indication in the treatment of the pains 
depending upon a morbid condition of the stomach and 
intestine is to suppress the pathogenic cause. Thus by 
neutralizing the hyperacidity we overcome the pain re- 
sulting from it. This result is particularly noticeable in 
cases of hyperchlorhydria; the exhibition of alkalies in 
large doses suppresses the pain more promptly and effec- 
tually than all the narcotics which we could administer. 
The same result is obtained when alkalies are given in 
simple ulcer; the pain is relieved and at the same time the 
progress of the disease is arrested by the prevention of 
auto-digestion. Indeed, whenever an ulceration of the 
stomach exists, whatever its nature, it is proper to neu- 
tralize the gastric juice and thus suspend its corrosive and 
irritant action. 

Constipation is often the cause of severe colic located in 
the large intestine, especially when there is muco-mem- 
branous enteritis; in such cases it is the constipation espe- 
cially which calls for treatment. Sometimes a hemor- 
rhoidal condition is present which must be treated in order 
to relieve the enteralgia. 

Unfortunately we cannot always discover or reach the 
cause of the pain, and sometimes the phenomena are purely 
nervous in character, so that we are obliged to treat the 
element of pain directly. We are also occasionally obliged 
to have recourse to narcotic medication, even when it is 
possible to institute a causal treatment. This is an em- 
pirical and secondary, although important, treatment, 

142 



TREATMENT OF PAINFUL PHENOMENA. 143 

when there is some evident anatomical or chemical cause 
for the pain residing in the disease itself; but it becomes 
the principal thing when the cause escapes our means of in- 
vestigation, or when the pain seems to be purely neuralgic 
in character. 

The reader will find elsewhere, either in the part devoted 
to dyspepsia or in that treating of organic diseases with 
evident lesions, a discussion of the pathology of these 
symptomatic pains. We shall in this place review briefly 
the other gastro-intestinal pains, such as gastralgia, en- 
teralgia, and the gastric and intestinal crises* 

Gastralgia. — The domain of gastralgia, formerly so ex- 
tensive, has been greatly narrowed as a result of modern 
research. We must withdraw from it tye painful parox- 
ysms occurring in hyperchlorhydria and the crises of loco- 
motor ataxia. The unpleasant sensations, hardly painful, 
of weight and of epigastric pressure, so frequent in pa- 
tients suffering from simple nervo-motor dyspepsia, do 
not really deserve the name of gastralgia. 

Gastralgia is a painful cramp of the stomach, coming 
on at no definite period after eating. This pain which is 
sometimes very severe, is eased by pressure at the pit of 
the stomach. Occasionally accompanying this pain is a 
very marked feeling of depression, amounting almost to 
syncope ; the face is pale, anxious, and sometimes covered 
with a cold sweat. The pains are not relieved by the in- 
gestion of food or drink, being thereby distinguished from 
those occurring in hyperchlorhydria. These painful crises, 
so capricious in the time of their appearance, are met with 
especially in the chlorotic, the hysterical, and in women 
with movable kidney, who may or may not have previ- 
ously suffered from the violent gastric crises with vomit- 
ing which we shall describe later on. They may also 
occur in the neurasthenic or in those of the rheumatic 
diathesis. 

Enteralgia is not so well recognized as gastralgia. Ger- 
main See, having observed that the pain in many cases of 
dyspepsia did not occur until three or four hours after 



144 DISEASES OF THE STOMACH AND INTESTINE. 

meals, came to the conclusion that their real seat was in 
the intestine. There is no doubt that colic may occur in 
these cases, but still we must remember that late pains in 
the stomach occur in cases of hyperchlorhydria. 

Enteralgia is a sharp pain, characterized by the patient 
as colic, spasm, or a burning sensation, following the 
course of the transverse colon or sometimes almost com- 
pletely encircling the abdomen, like the colon itself. These 
crises are occasionally extremely painful ; they may con- 
tinue for hours or even for days. Frequently they come 
on rather late at night, between two and three o'clock in 
the morning. The patient is bent almost double, com- 
pressing the abdomen with his forearms; his condition is 
at times one of extreme distress and anxiety. 

At times we see movable prominences on the abdomen 
due to the spasmodic contraction of the muscular tunics 
of the intestine. These elevations are readily displaced 
and are seldom found in the same location in two consecu- 
tive attacks. 1 Occasionally exaggerated peristaltic move- 
ments may be seen through the abdominal walls, and 
gurgling or rumbling noises may be heard (the tormina ner- 
vosa of Kussmaul). Similar crises are common in patients 
with muco-membranous colitis and hemorrhoids. Some- 
times the pains radiate toward the sides of the chest, the 
loins, or the vertebral column. 

Cherchewski 2 has seen analogous crises which were 
manifested by rectal tenesmus and a peculiar appearance 
of the faeces which looked as though they had been passed 
through a gauge -plate or were in the shape of little oval 
balls. 

The intensity of the pain and the retraction of the ab- 
domen have occasionally led to a diagnosis of lead colic. 
Vomiting is absent, however, in these cases, and when 
this symptom is present we are led to suspect an actual 
occlusion of the intestine. 

1 G. Andre : " Les Nevroses de l'lntestin, " Gazette Hebdomadaire, 
December 17th, 1892. 

9 Revue de Medecine, October and December, 1883. 



TREATMENT OF PAINFUL PHENOMENA. 145 

Spasm of the intestine plays an important part in the 
mechanism of this form of enteralgia, and it is possible 
indeed that the pain may be at times of purely spasmodic 
causation. A proof of the irregularity and exaggeration 
of the intestinal peristalsis is found in the borborygmi, 
which are perceptible both to the eye and to the hand, and 
also in some cases by knots forming along the course of 
the bowel. The crisis may terminate in an alvine evacua- 
tion. In rare instances faecal matters are ejected by the 
mouth, an indication of very intense anti-peristaltic action. 

Gastric Crises. — It is to Charcot 1 that we owe our 
knowledge of the gastric crises which occur most fre- 
quently in locomotor ataxia, but which are also seen in 
other cerebro-spinal diseases, such as general paralysis, 
sclerose en plaques, subacute or chronic central myeli- 
tis, etc. 

Crises of tabes, which like the lancinating pains and 
the visual disturbances are frequent in the pre-ataxic 
period, manifest themselves in typical cases in the follow- 
ing way. Patients begin by having fulgurating pains in 
the lower extremities, sometimes also in the upper, girdle 
pains, and finally an acute pain in the epigastric region 
which is occasionally so severe as to find expression in 
loud cries. Vomiting then occurs, not preceded by nausea, 
but with a gush; the ejected matters consist at first of 
debris of food, then become glairy, and finally bilious. 
The vomiting puts an end momentarily to the paroxysm, 
but the pain reappears after a longer or shorter period of 
absolute freedom. There is a hypersecretion of hydro- 
chloric acid during the crisis, as has been stated by Sahli 
and other observers, but hyperchlorhydria is rare in these 
conditions, and I myself have seen it but once in some ten 
or more cases. There is no reason, therefore, for giving 
alkalies in large doses indiscriminately in all cases of this 
kind. I have found, indeed, in several cases that the 
vomited matters were alkaline, the result, no doubt, of a 

1 "Lecons sur les Maladies duSysteme Nerveux, " 2d edition, vol. 
ii., page 32. "Lecons du Mardi, " page 331, 1888-89. 
10 



140 DISEASES OF THE STOMACH AND INTESTINE. 

reflux into the stomach of the intestinal contents, and es- 
pecially of the bile. 

The crises may last, in this way, with exacerbations and 
remissions, for several successive days. Eating is impossi- 
ble during their continuance, but as soon as the pain has 
ceased, which it does suddenly, the patient begins to eat 
again as if nothing had happened ; there is no anorexia 
and digestion is well performed. These intervals of per- 
fect freedom from pain and the rapid termination of the 
crises are points of value in the diagnosis. 

The gastric crises of locomotor ataxia vary greatly in 
their course and in their intensity. Charcot distinguishes 
the following clinical varieties : 

1. The}* may be of unusual intensity and reduce the 
patient to a dangerous condition of collapse. 

2. The pains are occasionally "crampoid" in character 
and are unattended with vomiting. These are the mild 
crises, well described by Founder as occurring in the 
preataxic stage of tabes, crises <i sec. 

3. Vomiting may be profuse and pain but slight. 

4. The crises may recur every day. 

5. They may be of long duration, lasting fifteen, twenty 
or thirty days or more. In one doubtful case, reported by 
Buzzard, the crises are said to have lasted for nine months. 

Gastric crises, absolutely resembling those of tabes, but 
occurring in simple neuropathic cases, independent of any 
medullary lesion, have been noted by various authors 
(Ley den, Debove, Remond). 1 

Charcot doubts the reality of these essential crises. He 
thinks that they properly belong to the pre-ataxic period 
of tabes, and that the patients in whom they were observed 
were destined eventually to become tabetic. We have, 
however, seen veritable crises of pain and of vomiting in 
women suffering from movable kidney. 2 

lu Ueber periodisches Erbrechen." Ztscb. f. klin. Med., Berlin, 
1882. Sock'-te Med. des Hopitaux, January 23d, 1889. "Des Crises 
Gastriques Essentielles, " Arch. GeD. deMed., July, 1889. 

- ,4 Les Crises de Yomissement chez les Malades atteints de Rein 
Mobile," Societe Medicale des Hopitaux, October 21st, 1892. 






TREATMENT OF PAINFUL PHENOMENA. 147 

These crises may resemble in every respect those of loco- 
motor ataxia ; they may be more or less intense and more 
or less prolonged, and there may be painful crises without 
vomiting. The exciting causes of the attacks are mental 
emotions of various kinds and overwork ; it is important 
to bear these causes in mind with reference to the treat- 
ment. They come on very commonly during the men- 
strual period. Attacks of this nature are far from being 
rare; I have seen fifteen cases in the past two years. In 
purely neuropathic gastric crises, associated or not with 
movable kidney, there is hypersecretion with acid vomit- 
ing, resembling indeed acute hyperchlorhydria. 

Intestinal Crises. — Fournier has drawn special atten- 
tion to intestinal crises occurring in locomotor ataxia, and 
has described intestinal tenesmus and tabetic diarrhoea. 
Tenesmus is characterized by urgent and frequent desire 
to defecate, although but little is passed at stool. We 
shall describe tabetic diarrhoea in a subsequent section. 

In the following review of the various agents employed 
for the relief of gastric and intestinal pain, we shall point 
out the special indications for their use in individual cases. 
It is well to note that most drags which have a sedative 
influence in pain are also capable of reducing the exag- 
gerated motor excitability, spasmodic condition, vomiting, 
and the gastric crises. In pointing out, therefore, the 
treatment for the gastric crises, we shall indicate in its es- 
sential features that suitable for the vomiting. 

Opium and its Derivatives. — Opium has long been 
employed in the treatment of pains in the stomach. In 
cases of painful dyspepsia Trousseau used to give a very 
small quantity of laudanum, beginning with one drop, at 
the commencement of a meal ; his object was to reduce the 
sensibility of the stomach without prejudice to its move- 
ments. Black drop has also been given in the same way 
and for the same end, and Dujardin-Beaumetz considers 
it an excellent remedy for the pain. One must not forget 
in giving this preparation that it is much more active than 
Sydenham's laudanum. The preparation is twice as rich 



148 DISEASES OF THE STOMACH AND INTESTINE. 

in opium as Rousseau's, and four times as rich as Syden- 
ham's laudanum. 

Paregoric is much less rich in opium, containing but 
four parts to the thousand, so that there is only about one- 
twelfth of a grain in twenty drops. The vinegar and tinc- 
ture of opium are most frequently taken before meals when 
the object is to relieve the pain occurring during digestion. 
The crude drug in powder is also used sometimes for the 
same purpose ; it is frequently incorporated in alkaline or 
absorbent powders such as bicarbonate of soda, calcined 
magnesia, prepared chalk, or subnitrate of bismuth. The 
following formulae will be found useful : 

I? Prepared chalk, 

Bicarbonate of soda, .... aa gr. viij. 

Powdered opium gr- h 

M. For one powder. Two or three may be taken 
at the beginning of a meal. 

\i Magnesia, 

Bicarbonate of soda, . . . a a gr. viij. 

Powdered opium, .... gr- h 

M. For one powder. To be taken in the same way 
as the preceding. 

These formulae are especially useful in cases of slight 
hyperacidity with true hyperesthesia of the mucous mem- 
brane. 

Opium is an excellent remedy for the intestinal pains, 
for colic especially. It may be taken in the form of ex- 
tract, of powder of the crude drug, 1 of laudanum, or of 
paregoric, according to the age of the patient and the spe- 
cial indications. Paregoric, which is easy to take, is par- 
ticularly serviceable in the case of infants because of the 
small proportion of opium which it contains. Laudanum 
may be given by enema in those cases in which vomiting 
is so persistent as to render its administration by the 
mouth difficult. 

Morphine.— This alkaloid is often useful in cases of 

1 The extract of opium is double the strength of the crude drug. 



TREATMENT OF PAINFUL PHENOMENA. 149 

acute pain, that of gastric crises for example. It may be 
given in solution or hypodermically, though its employment 
in solution is somewhat out of date. Gallard has devised 
a formula which he calls " white drops," and which is used 
in much the same way as the black drop. The following 
is the formula : 

1$ Hydrochlorate of morphine, . . . gr. vi. 
Cherry-laurel water, . . . . 3 v. 

A small dose of this solution, one or two drops on a lump 
of sugar, is given at the beginning of a meal. This prep- 
aration is very much weaker than the solution used for 
hypodermic injection, a dose of 2 drops containing only 
about 2V grain of morphine. Two or three times the 
amount advised by Gallard may be given if desired. 

When used to combat these gastro-intestinal pains mor- 
phine is usually employed in hypodermic injection. It is 
an excellent remedy in very acute pain, in round ulcer, 
and in gastric crises, especially when vomiting is present. 
At the beginning, before the individual tolerance of the 
patient is known, it should be given in small dose (^2 to 
£ grain). Recourse should be had to morphine only in 
cases of real necessity, and its use should be abandoned as 
soon as possible. The special reason for this is that pa- 
tients with gastric pains are often neurotics who are more 
exposed than others to the danger of contracting the mor- 
phine habit. 

Opium and morphine are also particularly indicated 
when there is a tendency to diarrhoea, and in cases of in- 
somnia. It may be noted that we have not recommended 
any preparations in the form of syrup. This is because 
sugar is not, as a rule, suited to dyspeptics, and it is there- 
fore better to use other pharmaceutical forms of adminis- 
tration. 

Belladonna. — Trousseau used to think highly of bella- 
donna for the relief of pains in the stomach and intestine. 
He gave the extract in initial doses of -J grain. This is 
exhibited in pill form made up with an equal amount of 



150 DISEASES OF THE STOMACH AND INTESTINE. 

the powdered leaves. It acts well in some cases, especially 
when constipation is present. 

Chloroform Water. — This is prepared most simply by 
adding two teaspoonfuls of chloroform to a pint bottle of 
water. The mixture is shaken several times during 
twenty-four hours, and the water is then decanted from 
the undissolved chloroform at the bottom of the bottle. 
This saturated solution of chloroform, recommended by 
Lasegue, is sometimes but not always an efficient sedative 
of the pain and vomiting. It is usually better to dilute it 
with an equal quantity of pure water, as it is apt in full 
strength to cause a burning sensation in the oesophagus 
when swallowed. It has the advantage that it can hardly 
be taken in overdose, and it may be given in quantities 
of from 3 to 5 tablespoonfuls every ten minutes during 
a period of from one-half to one hour. It may also be 
employed as a menstruum for a number of medicinal 
substances. In cases in which it acts well it is a very 
valuable remedy. 

Sulphide of Carbon. — A saturated solution of sulphide 
of carbon may be prepared and used in the same way as 
the preceding; it has been recommended by Dujardin- 
Beaumetz. 

Hydrochlorate of ('<><•<< in<>. — The anaesthetic effect 
which this drug exerts upon the mucous membranes has 
been utilized in painful affections of the stomach, often 
with good results. Dujardin-Beaumetz prescribes it in 
a solution containing 2 grains to '•) ounces of water, 
of which he gives :> tablespoonfuls every two hours. 
He says that as much as 3 or 8 grains of the salt may be 
taken in this way in the course of twenty-four hours 
without danger. We prefer to give much smaller doses, 
using a solution of only V grain to 3 ounces, of which 
not more than H ounces is taken in tablespoonful doses 
during the day. It should not be forgotten that very 
dangerous symptoms of acute poisoning have followed the 
exhibition of a single dose of j grain of cocaine. 1 Of this 

'Luther: Therapeutische Monatschrift, February, 1893, page 92. 



TREATMENT OF PAINFUL PHENOMENA. 151 

weaker solution a tablespoonf ul may be given every fifteen 
minutes for an hour, the administration of the remedy 
being then discontinued until the pains reappear. 

Extract of Cannabis Indica. — In a general way we 
may say that cocaine is stronger than chloroform water 
and cannabis indica is stronger than cocaine. The extract 
of cannabis indica is an excellent sedative for gastric pain; 
it is recommended by Germain See in daily doses of f 
grain. We begin usually with £ grain and rarely exceed 
% grain. The following formula is useful: 

^ Extract of cannabis indica, . . . gr. i 
Alcohol, . . . q. s. to make a solution 
Wate"r, 3 v. 

M. Sig. The entire amount to be taken in the 
twenty -four hours. 

Extract of cannabis not only relieves the gastric pains, 
but is an excellent analgesic in general. It acts well in 
the lancinating pains of tabes, in the various indefinite 
pains of neurasthenics, etc. Even when given in doses of 
•J- to \ grain a day, its effects must be carefully watched, 
for occasionally, after a few days' use, slight symptoms of 
acute hasheesh poisoning declare themselves ; such are fits 
of musing, hallucinations occurring in a half -waking state, 
nightmare, etc. It would not be prudent to continue the 
use of the drug longer in cases in which there is any im- 
perfect action of the kidneys. 

Solanine. — Desnos has experimented with this drug, 1 
and has noted very marked sedative effects in a variety of 
painful affections of the stomach. He gave it in pill form 
in daily doses of f to 1-J- grains, rarely exceeding 2 grains. 

Chlorodyne. — This preparation, of unknown composi- 
tion, enjoys a great reputation in England as a remedy 
for gastralgia, and is considered as an indispensable trav- 
elling companion by numbers of English and Americans. 
Several different formulae have been published as repre- 
senting its composition (see Appendix), but the active in- 
gredients are evidently chloroform and morphine. 

1 Bulletin General de Therapeutique, vol. cxxii. , p. 352. 



152 DISEASES OF THE STOMACH AND INTESTINE. 

We have less confidence in the following medicaments 
than in those which we have enumerated in the earlier 
part of this section : 

Ether. — This is much less efficacious than chloroform 
water. Nevertheless it may do good service in the case 
of very nervous individuals or of hysterical women, when 
given in doses of 10 to 20 drops in sweetened water. 

Menthol. — This substance may occasionally be found 
useful, especially when vomiting is troublesome. It may 
be given after the following formula : 

R^ Menthol, gr. iss.-ij. 

Alcohol, . . . q. s. to make a solution. 

Distilled water, . . . . § vi. 

M. Sig. To be taken in tablespoonful doses: 

The drug may be taken in much larger doses than these 
(see Appendix). 

Condurango. — Dujardin-Beaumetz speaks well of this 
substance. It may be given in powder in doses of 15 
grains at each meal; in alcoholic solution (1 : 5) in doses 
of 2 teaspoonfuls at cadi meal; or in the form of fluid 
extract in 20-drop doses after eating. We have never 
tried it. 

Nitrate of Silver. — Singular as it may appear at first 
Bight, Rosenheim ' lias found nitrate of silver an excellent 
sedative in cases of exaggerated sensibility of the mucous 
membrane of the stomach. He gives 2 teaspoonfuls in a 
half-glassful of water three times a day of a solution con- 
taining 3 to 4.' grains to 3 ounces of distilled water. The 
first dose is taken fasting, the others after breakfast and 
dinner. 

Antipyrin. — This excellent nervous sedative seems to 
have the disadvantage of acting as an irritant to the gas- 
tric mucous membrane, and it should therefore be em- 
ployed cautiously in all cases of dyspepsia, especially if 
gastritis is present. It is best given in combination with 
bicarbonate of soda, and may also be administered by the 
1 "Krankheiten der Speiserohre nnd des Magens, " p. 288. 



TREATMENT OF PAINFUL PHENOMENA. 153 

rectum. The best results from the use of the drug are ob- 
tained in cases of gastric crises, and it is known to be a 
useful remedy for the painful crises of locomotor ataxia. 
From 8 to 45 grains may be given, but it ought always to 
be administered in small dose and with caution in the case 
of persons who take it for the first time, for instances of 
idiosyncrasy in respect to its action are quite common. 

The Bromides. — All the bromides, even more than anti- 
pyrin, have the disadvantage of acting as irritants to the 
gastric mucous membrane. Germain See has recently 
recommended the bromide of calcium as a sedative in all 
cases of stomach pains ; he prescribes it in doses of from 
30 to 45 grains in the same way as bromide of potassium. 

We may conclude this review by mention of certain 
physical remedies, such as hot applications, baths, elec- 
tricity, and counter-irritation. 

Hot Applications, Baths. — The sedative effect of heat, 
especially moist heat (compresses or poultices) applied to 
the abdomen is well known and we may always avail our- 
selves of it. Hot baths have also a very soothing action, 
and may be prescribed with advantage in the case of pa- 
tients who are able to bear them, seeming to be of particu- 
lar efficacy in gastric crises. 

Electricity. — Several writers have spoken of the good 
effects of electrization in the treatment of painful affec- 
tions of the stomach. Leube has obtained excellent re- 
sults from a continuous current in gastralgia, 1 and Burk- 
hardt has derived benefit from faradism. 2 Max Einhorn, 3 
the inventor of a special apparatus for intra-gastric elec- 
trization, has also noted the disappearance of stomach 
pains under the influence of this mode of treatment. The 
following are the conclusions which Rave has formulated 
as the result of investigations conducted in Hayem's ser- 
vice : " The painful phenomena are, in a general way, re- 

^iemssen's "Handbuch, " vol. vii., p. 205. 
2 " Neurasthenia gastrica, " Bonn, 1882. 

3 N. Y. Medical Record, May 9th, 1891, and January 30th and Feb- 
ruary 6th, 1892; N. Y. MedicalJournal, July 8th, 1893. 



154 DISEASES OF THE STOMACH AXD INTESTINE. 

lieved by the judicious employment of the constant current ; 
but we must make an exception in regard to the crises 
which this treatment ma}' provoke in cases of hyperchlor- 
hydria." This exception is justified by the fact which has 
been shown by Rave and by Hoffmann, 1 that electrization 
of the stomach increases the gastric secretion. It would 
hardly be prudent to apply electricity to the pneumogas- 
tric nerve, as some have proposed, for the consequences 
might be unpleasant as regards the action upon the 
heart. 

The patient sometimes objects so strenuously to the intra- 
gastric method of electrization that Ziemsson now uses 
external treatment only, applied by means of broad elec- 
trodes. Faradism may be employed by preference in pa- 
tients in whom there is great relaxation of the abdominal 
muscles and constipation. 

Counter-irritation. — Revulsion is sometimes useful in 
the treatment of gastralgia. It may be obtained by means 
of sinapism^, sprays of methyl-chloride, or small blisters. 
We believe that the effect is produced chiefly through 
suggestion, for which reason it is better to employ some 
very superficial form of irritation which will net involve 
the skin to an}' great extent. The actual cautery should 
never be used, and it is a serious error to produce any real 
lesion of the integument by means of it. 

We will close this chapter with some remarks as to the 
special form of treatment best adapted to the relief of each 
of the varieties of gastro-intestinal pain. 

Pains Symptomatic of Dyspepsia. — Alkalies in large 
doses are the best means of overcoming the pains due to 
hypersecretion of hydrochloric acid. Nevertheless, in 
cases in which marked hyperesthesia of the mucous mem- 
brane exists, recalling veritable paroxysmal crises, it will 
be well to have recourse to sedatives. Hot drinks are 
often useful for this purpose. Among the medicinal seda- 
tives we would give the preference to opiates, cocaine, and 

1 Berliner klinische Wochenschrift, Nos. 12 and 13, 1889. 



TREATMENT OF PAINFUL PHENOMENA. 155 

especially to extract of cannabis indica. We ought not 
to think of emplo3~ing antipyrin or electricity because of 
the irritation which they cause to the mucous membrane. 
Hot baths and hot douches often have a favorable effect. 
They should be given whenever possible in the evening, 
in order to produce quiet and give the patient sleep at 
night. In simple nervo-motor dyspepsia, without any 
tendency to organic hyperacidity, we may use black drop, 
Gallard's white drops, or laudanum in very small doses at 
the beginning of a meal. Hot drinks are especially useful 
in these cases, since they increase the movement of the 
stomach at the same time that they relieve the pain. Of 
course the diet and medicinal treatment should be carried 
out in the way we have indicated above. We may also 
use in these cases chloroform water, which is a good anti- 
septic and is therefore indicated in cases of fermentation 
with organic hyperacidity. When there is dilatation, 
lavage will be found an effective remedy against pain. 
Counter- irritation finds its application especially in chronic 
gastritis, in round ulcer, and in the gastralgia of neurotics 
and the hysterical. 

Gastralgia and Gastric Crises. — In cases of very se- 
vere gastric crises, with or without vomiting, absolute 
rest is indicated. This is always useful and is indispens- 
able when there is a movable kidney. In the way of medi- 
cinal sedation we may give cannabis indica, chloroform 
water, cocaine, or hypodermic injections of morphine. Re- 
lief may sometimes be obtained by hot baths or electricity 
applied to the abdomen. Absolute rest and hot drinks are 
the best remedies in certain cases of crises with hyper- 
chlorhydria. 

Intestinal Pains. — The colic which accompanies diar- 
rhoea should be treated by opium or morphine, given by 
the mouth or rectum. In cases of chronic colitis remedies 
should be administered preferably by enema. Hot appli- 
cations are also frequently of great benefit. Opium has 
the disadvantage, in cases of muco-membranous colitis, of 
increasing the constipation which is in reality the cause 



156 DISEASES OF THE STOMACH AND INTESTINE. 

of the whole trouble; belladonna, as recommended by- 
Trousseau, is therefore to be preferred in this condition. 
Cherchewski has also employed it in cases of intestinal 
crisis with good results. When constipation is present, 
the application of electricity, especially of faradism to the 
abdomen, is indicated. 



CHAPTER V. 
VOMITING. 

Vomiting occurs as a symptom in so many different 
conditions that we cannot attempt even to enumerate them 
here, and must content ourselves with the general indica- 
tions for treatment of the symptom considered apart from 
the morbid condition of which it is the expression. Any 
special indications which may exist in individual cases 
will be found discussed in the several sections devoted to 
the therapeutic management of the different diseases in 
which vomiting may occur. 

Ice is frequently employed with success ; it should not 
be allowed to melt in the mouth, but should be swallowed 
in small fragments at successive intervals. We have often 
arrested the vomiting in cases of tuberculosis by causing 
the patients to swallow little pieces of ice immediately 
after eating. Cold acidulated drinks, effervescing lemon- 
ade, and champagne are likewise useful in many instances. 
The employment of Riviere's potion is classical ; 1 it should 
not be given in cases of round ulcer on account of the dan- 
gerous distention of the stomach which the carbonic acid 
might occasion. 

All the agents which are useful in relieving pain may 
be employed to arrest the vomiting; among these are 
chloroform water, cocaine, cannabis indica, and morphine 
by the mouth or hypodermically. Menthol has recently 

1 The " effervescing draught " of the French Codex consists of two 
solutions, which are mixed in equal parts when used and drank dur- 
ing effervescence. The first contains 2 parts of potassium bicarbonate 
in 15 of syrup and 50 of water ; the second contains 2 parts of citric 
acid in 15 of syrup of lemon and 50 of water. 

157 



158 DISEASES OF THE STOMACH AND INTESTINE. 

been recommended very highly in cases of obstinate vomit- 
ing. It may be given according to the following formula : 

I^ Menthol, gr. xv. 

Alcohol, . 3 v. 

Simple syrup, . . . -si. 

M. Sig. A teaspoonful every hour. ! 

Lasegue has found tincture of iodine, given internally in 
iodide solution, of service. We may also try nitrate of 
silver, as advised by Rosenheim for the relief of hyper- 
esthesia of the mucous membrane. For vomiting of preg- 
nancy the oxalate and the valerianate of cerium have been 
recommended. 

In cases of nervous vomiting we may also make use of 
counter-irritation in the form of sinapisms and blisters to 
the epigastrium, sprays of ether or of methyl-chloride, or 
electricity. Electrization of the pneumogastric in the cer- 
vical region has also been recommended, but we must con- 
fess that we should hesitate to employ this remedy. We 
should prefer faradization by moans of the electric brush. 
Static electricity and the electric bath may be tried. In 
cases of hysteria and of neurasthenia the physical remedies 
are especially advisable. For the former we might have 
recourse to suggestion. 

Lavage would be indicated in eases of stagnation of food 
in the stomach with acid fermentation. Forced feeding 
through the stomach tube sometimes succeeds when all 
other means have failed. It is an heroic measure to which 
we may turn in cases of need when no contra-indication 
exists to its employment (Debove). 

'Wins, quoted by Soulier : "Traite de Therapeutique, " vol. ii., 
294. 



CHAPTER VI. 
DISORDEES OF THE APPETITE. 

The appetite may be increased or diminished. Bulimia 
or exaggeration of the appetite is of uncommon occurrence 
except in diabetes and in convalescence from acute dis- 
eases. It is met with also in some cases of hypersecre- 
tion of hydrochloric acid; these patients are gluttonous 
and swallow their food without masticating it sufficiently. 
Outside of the condition above mentioned, bulimia is found 
chiefly among neurotics. It is to be treated by large doses 
of opium, extract of valerian (in gradually increasing doses 
from 1 to 2i drachms), and by antipyrin. 

A diminished appetite will be benefited in the ordinary 
cases by the local and general treatment directed against 
the dyspepsia ; climatotherapy, hydrotherapy, and massage 
are especially useful. 

Among the medicinal substances used to promote the 
appetite the bitters, such as gentian, quassia, and nux 
vomica, have long enjoyed a high reputation. These bit- 
ters should generally be given a little while before meals, 
but it is better to take tincture of nux vomica and gouttes 
ameres de Became (a tincture of St. Ignatius bean — see 
Appendix) immediately before meals, or sitting down to 
the table. We prefer to prescribe the bitter tinctures after 
meals, while digestion is in progress. Infusion of quassia 
is inoffensive and may be taken fasting without trouble, 
but this is not the case with the vinous or alcoholic prep- 
arations, which in the course of time induce secretory 
exhaustion of the mucous membrane, or even lead to actual 
gastritis. We must regard as specially dangerous in this 
respect all those preparations advertised under the falla- 

159 



160 DISEASES OF THE STOMACH AKD INTESTINE. 

cious appellation of appetizers. There is a large consump- 
tion of them in these days, but all of them, whatever name 
they go by, are as injurious as absinthe, and as likely to 
lead to gastritis or to that particular form of intoxication 
by essences which Lancereaux so justly distinguishes from 
alcoholism. 

Wine of gentian or of calumba and similar preparations 
sjiould be taken during digestion. Beer taken with the food 
is a good appetizer. The appetite is also increased by hy- 
diochloric acid in small doses; this effect is seen especially 
in the dyspepsia and anexoria occurring in tuberculosis. 

In some cases of neurasthenia the patients acquire a 
veritable disgust for food, and instances are related of per- 
sons thus affected who have died apparently of simple in- 
anition from not eating enough. It is in these grave cases 
that we must resort to the Weir-Mitchell method of treat- 
ment. Feeding by the stomach tube is often of the greatest 
service; the patients are brought out of their depressed 
condition, regain their strength, and acquire a taste for 
food again. Isolation, with or without forced feeding, is 
also the best means of treating hysterical anorexia, which 
is due in most part to a perversion of the will. 

Dujardin-Beaumetz regards arsenic as the best remedy 
for simple loss of appetite; it may be tried in the milder 
cases of the class we have just been considering, in those 
who are still able to attend to their affairs, to travel, etc. 

Orexine hydrochloride, a preparation lately introduced, 
appears to be of little value, certainly much inferior in its 
action to hydrochloric acid. 



i 



CHAPTER VII. 
CONSTIPATION. 

Definition. — It is as difficult to define constipation as it 
is to say what is diarrhoea. As will be seen, we shall de* 
fine diarrhoea as consisting in the elimination of an exces- 
sive quantity of fluid by the intestine. Constipation is 
exactly the opposite condition. It is the stagnation in the 
bowel of faecal matters which undergo a more or less 
marked degree of desiccation. This definition excludes 
those cases in which there is, as occurs sometimes in 
cholera, a sort of internal diarrhoea. Very soft, even liquid 
matters are retained in the intestine, but one cannot logi- 
cally say that there is constipation. The retention may 
be incomplete, a part only of the faecal matter being evacu- 
ated; or the liquid matter may force a channel through the 
hardened scybala. Sometimes diarrhoeic attacks occur, 
but these are cases of false diarrhoea behind which real 
constipation exists. All that is perfectly reconcilable 
with the definition which we have proposed. 

Writers have classified constipation under different va- 
rieties according to their causes, symptoms, and conse- 
quences. None of these classifications is entirely satisfac- 
tory and we shall not trouble ourselves much with them, 
following the one by preference formulated by Dujardin- 
Beaumetz. This author groups the different forms of 
constipation under the five following heads : 

1. Constipation due to a mechanical obstacle. 

2. Constipation of alimentary origin. 

3. Absence of secretion of the intestinal juices. 

4. Diminution of the muscular contractility. 

5. Constipation resulting from disordered sensibility of 
the rectum, under which we distinguish two sub- varieties : 

11 161 



162 DISEASES OF THE STOMACH AND INTESTINE. 

(a) Anaesthesia (as in certain diseases of the spinal cord, 
transverse myelitis, etc.). 

(b) Painful spasm of the sphincter. 

This classification is perhaps the best that we have. 
But it is based on pathogeny, and the objection ma}' be 
raised that it brings together forms of the affection which 
differ greatly in their cause and clinical course. For ex- 
ample, constipation due to absence or insufficiency in the 
secretion of intestinal juice includes the constipation oc- 
curring in diabetes and that of patients with copious and 
persistent vomiting. 

We shall not consider here the forms of constipation 
which would naturally be studied in subsequent chapters, 
as, for example, that which results from a narrowing or 
compression of the intestine. We shall concern ourselves 
here only with habitual constipation which might be quali- 
fied as dyspeptic, and would come very appropriately in 
this place. 

Constipation is common in various forms of dyspepsia. 
It fills an important position in the semeiology of most of 
the varieties of gastric dyspepsia. Germain See regards 
it as one of the mosl active causes of atonic dyspepsia, 
which is as often accompanied by flatulence. The gases 
accumulate behind the obstacle formed by the stagnating 
faecal matters, and the distention then proceeds from below 
upward, from the large intestine to the small intestine and 
stomach. The affair is still more serious when hemor- 
rhoids are present, which offer a greater or less obstacle to 
defecation, lucre is some truth in this rather too mechani- 
cal conception of flatulent dyspepsia. Constipation is al* 
ways an aggravating condition in dyspepsia and we can- 
not hope to cure the latter unless we also relieve the former. 
The constipation is itself secondary; it is atonic and con- 
secutive usually to a general 'neurotic condition, neuras- 
thenia, hysteria, or arthritism. 

In hyperchlorhydria we find another factor in the 
frequent vomiting, by means of which much fluid is re- 
moved from the intestinal tract, resulting in more or less 



CONSTIPATION. 163 

desiccation of the contents of the lower portions of the 
canal. 

Constipation is therefore one of the most frequent occur- 
rences in those belonging to the general family of neurotics. 
Among these we find simple neurotics ; the arthritic, the 
gouty, and the obese; sufferers from diabetes in whom 
glycsemia exists as an additional factor ; the neurasthenics 
with or without movable kidney ; the hysterical, the epi- 
leptic, and the insane. We believe that chlorotic indi- 
viduals, who so often suffer from constipation, belong 
equally to this neurotic family. Mental disturbances are 
also often the cause of true neurasthenic constipation. 

Women suffer more often from this condition than men, 
a fact which is capable of explanation in several ways. 
They are more nervous, they have a wider pelvis, and 
finally, successive pregnancies often lead to a relaxation of 
the abdominal walls, an enteroptosis, which favors stag- 
nation of the intestinal contents. The aged suffer from a 
functional atony of all their organs, and even a true atrophy 
of the coats of the bowel, and consequently are often con- 
stipated. The condition is sometimes so pronounced in 
them as to give rise to symptoms of actual intestinal ob- 
struction. 1 

The predisposition to constipation is often increased by 
a faulty hygiene, such as the abuse of nitrogenous foods, 
want of exercise, and a habit of deferring visits to the 
closet. The latter cause is frequent with women and chil- 
dren. This faulty hygiene, aided sometimes b} r severe 
intellectual labor, tends to increase still more the pre-exist- 
ing diathetic condition ; it is a vicious circle. 

Degrees and Clinical Forms. — Most atonic dyspeptics 
suffer after eating from a feeling of weight, redness of the 
face, somnolence, and distention of the abdomen. Defeca- 
tion is difficult and often rendered more so by the presence 
of hemorrhoids. Sometimes these patients are constipated 
unknown to themselves; they go regularly to stool, but 
there is an insufficient evacuation. Others suffer from 
1 G. Thibierge : These de Paris, 1884. 



164 DISEASES OF TlIK STOMACH AND INTESTINE. 

more obstinate constipation, never having a natural pass- 
age, and obtaining relief only b} r means of injections or 
purgative medicine. 

We find often in these condition a general malaise, loss 
of appetite, headache, occasionally fever, a coated tongue, 
and gastric distress passing sometimes even into a typhoid 
state. With some patients, especially those of advanced 
age, the general condition deteriorates, the appetite is lost, 
there is even a disgust for food, and there may be vomit- 
ing, with abdominal pains radiating toward the lumbar 
regions and the thighs, in the parts supplied by the sciatic 
or the crural nerve. The question may then arise whether 
there is not a cancerous lesion, either of the stomach or of 
the intestine. It has even happened that scybala collect- 
ing in the course of the large intestine have been mistaken 
for malignant tumors. 

Another type of constipated persons is the constipe' a 
gros ventre. Patients of this class are more or less 
obese, have a prominent abdomen, a red face, and suffer 
from difficult respiration and from indigestion. Sometimes 
the abdomen becomes so distended as to excite the suspicion 
of an organic lesion, but the diagnosis is finally made clear 
by an enormous discharge from the bowels. 

( 'amplications. — The following are the most important : 
hemorrhoids, fissure of the anus, muco-membranous en- 
teritis, auto-intoxication, intestinal obstruction, and ileus. 

Auto-intoxication will be studied in the section on gas- 
trointestinal antisepsis, and obstruction and occlusion will 
be considered when we come to diseases of the intestine. 
The other complications will be noticed in the appropriate 
place in the following section. 

Treatment. — Notwithstanding the self-evidence of the 
statement, we must repeat that the first thing to do is to 
suppress as far as may be the essential or occasional causes 
of constipation, Thus we must treat the neurotic condi- 
tion in the neurasthenic, the ghycaemia in the diabetic, and 
the plumbism in those suffering from lead colic. The most 
frequent occasional causes are those in the domain of hy- 






CONSTIPATION. 1G5 

giene, such as improper food, want of exercise, etc. We 
must always, then, make inquiries on these points, for they 
may often lead to the formulation of very important direc- 
tions, more important even than the giving of medicine, 
since our aim ought always to be to bring about a cure if 
possible through the institution of hygienic measures. 
Ph}*sical remedies are alwa} T s to be preferred to medicinal 
ones, since they are more nearly related to the hygienic. 

We shall take up in their order, (a) the hygienic, (b) 
the mechanical, (c) the medicinal treatment, and (cl) the 
treatment of complications. 

(a) Hygienic Treatment. — Constipation is of ten caused 
and always increased by a diet which leaves but little resi- 
due, such as one of meat or nitrogenous food in general. 
In the normal condition it is the undigested residue of the 
food which, by stimulating the secretion and the contrac- 
tile power of the intestine, prevents undue desiccation of 
its contents and favors their evacuation by increasing 
peristalsis. The diet which we are often obliged to pre- 
scribe for dyspeptics has, therefore, the disadvantage of 
favoring constipation. 

Eggs act in the same way as meat, and as to milk the 
lay belief that it is laxative is erroneous. The truth of the 
matter is that people who are not accustomed to its use, 
and who take large quantities at once, frequently have at 
the beginning a temporary diarrhoea, but nine times out 
of ten that does not continue long, and constipation quickly 
supervenes. This offers occasionally a serious objection 
to a milk diet. When milk is taken in large quantities, 
colorless pasty matter, rich in fat, accumulates in the large 
intestine and is dislodged with difficulty. Injections of 
water have but little effect upon this fatty material and it 
would be better to use oil. Sometimes the accumulation 
of matter in the lower part of the rectum is so great as to 
prevent the injection of any liquid, and we have then to 
effect its removal by mechanical means, the finger, a spoon, 
or a spatula. 

Water strongly impregnated with lime seems to favor 



106 DISEASES OF THE STOMACH AND INTESTINE. 

constipation. Impure water taken from rivers and other 
polluted sources often causes diarrhoea by reason of its 
richness in organic substances and micro-organisms ; but 
this is not a therapeutic action of which we can avail our- 
selves, it is rather a pathogenic effect that we should avoid. 

Too much intellectual work combined with insufficient 
exercise tends to provoke, maintain, and aggravate torpor 
of the intestine. People are sometimes careless about the 
time of going to the closet and thus acquire a bad habit of 
neglecting the calls of nature. They should be advised to 
go to stool regularly at the same hour every day, whether 
they feel an inclination to do so or not. There is an ele- 
ment of auto-suggestion in this practice the value of which 
is not to be despised. In matters of hygiene .little things 
are not always the leasi good. It goes without saying 
that we should recommend those practices which are ex- 
actly the reverse of those which have a tendency to pre- 
vent a free action of the bowels. 

In the matter of diet, we should advise the taking of 
food which furnishes a large residue in undigested ma- 
terial, provided always that this residue is not too great or 
of too coarse a nature, such as would irritate or even injure 
the mucous membrane of the intestinal tract. Vegetables 
and green fruits answer our purpose in this respect very 
well. In order to reduce to a minimum the injurious effect 
upon the stomach of a large amount of indigestible vege- 
table substances, it is «>i'ten well to give only cooked fruit 
and vegetables in the form of purees. The vegetarian 
diet, described in a previous section, would be indicated 
in dyspepsia complicated by constipation, provided there 
is neither hypersecretion of hydrochloric acid nor marked 
stagnation of food in the stomach. We may mention here 
the employment of certain inert seeds, such as hulled lin- 
seed, white mustard, and psyllium plantago (fleawort). 
These may be given in doses of one to three teaspoonfuls 
in the morning before breakfast or once or twice a day at 
the beginning of a meal. A mucilaginous water having 
laxative properties may also be prepared from linseed or 



CONSTIPATION. 167 

psyllium by steeping one ounce of the seed in five or six 
ounces of cold or tepid water for about six hours and then 
straining. 

Mechanical Treatment. — Under this one heading we 
include both the physical and the mechanical measures. 
They are gymnastics, massage, hydrotherapy, enemata, 
ascending douches, suppositories, and electricity. 

Gymnastics. — By this term we mean not only gymnas- 
tics, as the word is generally understood, but also the per- 
formance of special exercises of the abdominal muscles. 
Bodily exercise is of great use in the case of those who 
lead sedentary lives, especially if they have a tendency to 
gout or obesity. The object of the special exercises is to 
give more strength to the walls of the abdomen ; these ex- 
ercises consist in principle of movements of the trunk, 
made while the patient is standing or recumbent, against 
a gradually increasing resisting force. Respiratory move- 
ments performed chiefly with the abdominal muscles are 
also useful. 

Massage. 1 — The following is the method of abdominal 
massage recommended by Berne : First knead the integu- 
ment and then the muscles of the abdomen, pressing gently 
with the palmar extremities of the fingers in the right iliac 
fossa ; then execute a massage of the entire colon with the 
closed fists. This massage should be at once very gentle 
and very deep. Care must be taken to see that the patient 
has passed water before the massage is begun, and that 
there is no abdominal tumor nor a vesical calculus. Each 
seance should last from fifteen to twenty minutes. It will 
be well, we may add, to make pressure along the colon in 
the direction which its contents take from the caecum to 
the rectum. 

Occasionally use has been made of a method called " ball 

1 Dujardin-Beaumetz : " Hygiene Therapeutique, " p. 83, 1888. 
Soulier: "Traite de Therapeutique," vol. ii., p. 768. Hirschberg : 
1 Massage de 1' Abdomen, " Bulletin de Therapeutique, p. 248, 1887. 
Berne : "Traitement de la Constipation par le Massage Abdominal," 

1887. 



168 DISEASES OF THE STOMACH AND INTESTINE. 

massage. " To execute it we employ a wooden ball covered 
with a piece of flannel, or, as Sahli ' recommends, a cannon- 
ball from three to five pounds in weight. The patient lies 
on his back and rolls this ball himself over the abdomen. 
We have sometimes used this method with apparent bene- 
fit. Massage is an excellent remedy for constipation, and 
often succeeds where all other means have failed. 

Hydrotherapy may be indirectly useful. Cold or hot 
douches used in the treatment of the neuropathic condi- 
tion serve at the same time to overcome the constipation. 
Sometimes local douching of the abdomen is practised, but 
we do not recommend this very highly. Nevertheless we 
can bear witness to the good effects of moist applications, 
cold or hot compresses; large poultices act in the same 
way. Baths are useful, especially if combined with inns- 
sage. The patient may himself, while in the bath, execute 
methodical petrissage of the abdomen. 

Injections. — These may act in a purely mechanical way, 
but we can increase their effect by adding purgatives or 
substances which, though not properly speaking purgatives, 
so irritate the mucous membrane of the rectum as to bring 
about more active contraction of the muscular coats of the 
colon and a more profuse glandular secretion. 

We may use simple hot or cold water (the latter is the 
more active), or emollients, such as bran-water, infusion 
of marshmallow, decoction of linseed, psyllium, etc. 
Aqueous enemata act in proportion to their volume. For 
an adult we should use at least a pint of liquid. To render 
its laxative effect greater we may add sea-salt, honey, or 
miel de mercuriale.* The best and most active substance 
is glycerin. This may be simply mixed with the water 
in the proportion of from 1 to 3 tablespoonfuls to the pint. 
The action of glycerin may be increased by giving first 2 or 
3 tablespoonfuls in 3 or 4 ounces of water ; this injection 
is retained for twenty-five or thirty minutes, and then an- 
other large enema of tepid water is given. The glycerin 

1 Centralblatt fur klinische Medicin, p. 280, 1888. 

2 A mixture of the fresh juice of mercurialis annua and honey. 



CONSTIPATION. 1G9 

provokes a more or less abundant secretion and thus pre- 
pares the inspissated contents of the bowel for the action 
of the evacuating enema. 

Oil may take the place of glycerin. Two or three table- 
spoonfuls are emulsified by means of the yolk of an egg, 
and this is then given either in a large enema or in a small 
one in the same way as the glycerin. Recently large in- 
jections of oil have been recommended. 1 The patient rest- 
ing on the back with the pelvis raised, about a pint of oil, 
heated to the temperature of the body, is slowly intro- 
duced, about twenty minutes or more being consumed in 
the process. To facilitate the penetration of the oil, the 
patient lies first on his left side, then on his right, so that 
the oil may flow into the large intestine through the force 
of gravity. It is rare that the initial injection reaches the 
caecum, and we can seldom introduce more than from 3 to 
8 ounces of oil at the first operation. The evacuation 
which follows this injection does not usually take place 
before the expiration of several hours, and several such 
enemata are needed in order to empty the large intestine 
completely. Very pure oil should be used, virgin olive 
oil being recommended by Fleiner. 

We may add 6 or 8 drachms of sulphate of soda to the 
water used in an ordinary enema. This is hardly more 
active than a glycerin injection, but its efficiency is 
greatly increased by the addition to the soda of a decoc- 
tion of senna. 

Ascending douches are really only large injections given 
in a peculiar way ; they are indicated especially in muco- 
membranous enteritis, and we shall describe them when 
treating of this condition. 

Suppositories are sometimes useful when injections have 
failed. This is especally the case when there is impaction 
of the sigmoid flexure, and of the rectal ampulla, so as to 
prevent the passage of a sufficient quantity of liquid into 
the large intestine. The suppositories excite a more or 
less abundant secretion, which softens and lubricates these 
1 W. Fleiner : Berliner klinische Wochenschrift, 1893. 



170 DISEASES OF THE STOMACH AND INTESTINE. 

masses and effects their expulsion. Simple cocoa butter 
may be used, or when there is much pain or tenesmus, as 
is common in cases of hemorrhoids, we may add from J 
to J grain of belladonna. Glycerin suppositories are 
much more efficacious. These were made originally of 
hollow cones of cocoa butter filled with liquid glycerin, 
but lately a method has been found of solidifying the gly- 
cerin by incorporating it with gelose (a gelatinizing prin- 
ciple derived from agar-agar), and then moulding it into 
suppositories which are easy to use and very effectual. 
An operation usually occurs two or three hours after their 
introduction. 

Electricity. — We may use any one of the three forms, 
static, faradic, or galvanic. 

Static electricity is of special service in cases of neuras- 
thenia. 1 The patient, resting on an insulated table, is 
brougth into communication with the negative pole of a 
static machine. It is usually sufficient to draw a series of 
sparks from the left iliac fossa in order to produce an evac- 
uation in a short time. 

The faradic current may be used externally or in the 
form of electrical injections. By the external application 
of currents of moderate intensity we effect electrization of 
the abdominal muscles which may be of advantage in eases 
of laxity of these tissues. Faradism may also be applied 
internally by means <>f one electrode introduced into the 
rectum and the other placed in contact with the skin of 
the epigastric or lumbar region. There is no tear of caus- 
ing an ulceration of the intestinal mucous membrane by 
electrolytic action when this form of electricity is em- 
ployed ; nevertheless wo think it is preferable to resort to 
continuous currents, which are so much more easily con- 
trollable. 

In the application of galvanism the negative pole is in- 
troduced into the rectum, previously filled with water, so 
that the current may be diffused over a large surface; the 

1 Vigouroux : Appendiceau "Traite de la Neurasthenie de Levil- 
lain." 



CONSTIPATION. 171 

electrode is inclosed in a rubber tube pierced with holes. 
The positive electrode, made of a broad cake of clay or a 
metal plate covered with moistened chamois, is placed on 
the epigastric or lumbar region. Currents of ten to fifteen 
milliamperes are passed for a period of twenty minutes. 




Fig. 3. —Electric Canula of Boudet, of Paris. 

The currents should be interrupted from time to time, or 
they may be reversed. 

Medical Treatment, Laxatives. — The first recom- 
mendation which we have to make is to employ drugs as 
seldom as possible in the treatment of constipation, and 
never until hygienic measures have proved ineffectual. 
Another principle to be borne in mind is never to resort to 
active purgatives for the relief of habitual constipation. 
The drastics should in a general way be proscribed, being 
reserved for the treatment of other cases in which a special 
indication may exist. 

The saline purgatives have the special disadvantage that 
their action is always followed by constipation, which is 
obstinate in direct proportion to the degree of action pro- 
duced by the drug. This fact is so well recognized that 
the salines are often employed in the treatment of diar- 
rhoea. These salts, whether artificially prepared or exist- 
ing naturally in mineral waters, should be used only in 
exceptional instances, as when no evacuation has taken 
place for several days and we desire to provoke one im- 
mediately without waiting for the slower action of other 



172 



DISEASES OF THE STOMACH AND INTESTINE. 



remedies. This first movement may be facilitated by the 
simultaneous employment of injections or suppositories 
When this preliminary clearing out has been effected we 
must rely upon the action of enemas, hygienic measures, 
or laxatives for a cure of the condition. As the patients 
quickly become habituated to the action of one remedy, 
we must change from time to time while following the 
general line of conduct which we are about to indicate. It 
is well to remember also that there are occasionally idio- 
syncrasies in respect to even the mild purgatives, tbe ex- 
istence of which we can discover in individual cases only 
through experience. A certain drug may act well in one 
case and produce intolerable colic in another. We must 
therefore proceed with caution at the beginning of a course 
of treatment, feeling our way until we have learned what 
remedy is best suited to the particular case in hand. 

Magnesia.— This drug has in a general way the advan- 
tage of being a mild laxative which is easy to take because 
of its almost complete absence of taste. It is particularly 
serviceable when alkalies are indicated, as it neutralizes 
four times as much acid as an equal weight of bicarbonate 
of soda. Its disadvantages are its insolubility and the 
readiness with which patients become habituated to its 
action. There are several kinds of magnesia in use, viz 
calcined and heavy magnesia, hydrate of magnesia, and 
the hydrocarbonate or white magnesia, Calcined magne- 
sia is especially useful when we desire to obtain an antacid 
as well a. a laxative effect. Heavy magnesia, according to 
Patem, is inferior to the light form, of which it has neither 
the absorbent power nor the ready solubilitv in acids 
On the other hand, it has the advantage of presenting a 
greater weight in less volume. Hydrate of magnesia is ob- 
tained by boiling calcined magnesia with twenty times its 
weight of water. Its action is milder than that of calcined 
magnesia, but it is seldom emploved. White magnesia 
which is often prescribed, is chemically a hydrocarbonate' 
It occurs m the form of a very light, white powder, almost 
insoluble in water. It dissolves in water acidulated with 



CONSTIPATION. 173 

carbonic acid gas, forming with the latter a bicarbonate. 
It is given in about double the dose of calcined magnesia, 
and is used by preference when a laxative rather than an 
antacid effect is desired. 

Magnesia is often mixed with other substances, such as 
bicarbonate of soda, chalk, or subnitrate of bismuth, when 
the neutralization of acids is aimed at; salicylate of bis- 
muth or naphthol when an antiseptic action is sought for; 
or with other laxatives, such as senna, sulphur, or cascara 
sagrada. Calcined magnesia produces a purgative effect 
in adults in doses of 2^ to 5 drachms ; to obtain a laxative 
effect from -J- to 1 drachm will suffice. We may begin with 
a half-teaspoonful, increasing the dose at subsequent ad- 
ministrations, until the desired effect is obtained. To 
children under one year of age 4 or 5 grains may be given 
twice a day, and to older children from 8 to 30 grains, 
beginning with the smaller dose. The purgative action 
of magnesia, like that of almost all the laxatives which we 
are about to study, is rather slow ; it will usually, there- 
fore, be sufficient to give it with the meals or at bedtime 
in order to obtain an evacuation in the morning. This is. 
an advantage, as the bowels are thereby made to move at 
the most desirable time for the formation of a healthy 
habit. 

The French Codex contains, under the name of " white 
medicine, " the following preparation : 

I£ Calcined magnesia, . . .8 grammes. 
White sugar, ..... 50 " 

Orange -flower water, . . .20 
Water, 40 

The water containing the magnesia is boiled, then the 
sugar and orange-flower water are added, and the mixture 
is strained. The orange-flower water may be replaced by 
any other flavoring substance. 

The shops contain chocolate and magnesia lozenges 
composed of 3 grains of scammony and 1 drachm of cal- 
cined magnesia ; the dose is 1 or 2 lozenges. There is also 
a preparation of granular magnesia containing one-quarter 



174 DISEASES OF THE STOMACH AXD INTESTINE. 

its of weight of magnesia, which may be given in doses of 
4 teaspoonfuls as a purgative and i to 1 teaspoonful as a 
laxative and antacid. 

We often employ with benefit a powder prescribed by 
Germain See. It is composed of equal parts of calcined 
magnesia, cream of tartar, and precipitated sulphur. From 
1 to 3 teaspoonfuls a day are taken in a little water at 
meal time. The insolubility of this powder is its only dis- 
advantage. A little liquorice may be added, and we then 
obtain a powder which differs from that known as com- 
pound liquorice powder in that it contains no senna. The 
following is a formula of a compound liquorice powder, 
devised by Dujardin-Beaumetz, which is an excellent 
preparation : 

I* Alcoholic extract of senna (powdered), 

Sublimed sulphur, . . aa 6 grammes. 

Powdered fennel, 

Powdered aniseed, . . . aa 3 " 

Pulverized cream of tartar 

Powdered liquorice, . . . aa 2 " 

Powdered sugar, . . . gg " 

This is taken in the same dose as the preceding. 

In cases of atonic dyspepsia, especially when there is 
flatulence, I occasionally add a small quantity of powdered 
ipecac to a laxative powder, similar to the preceding, as 
for example : 

K Magnesia, 

Precipitated sulphur, 

Cream of tartar, 

Powdered liquorice, . . . aa 20 grammes. 

Powdered ipecac, . . . 0.3 " 

Fluid magnesia of the French Codex contains 20 
grammes of hydrocarbonate of magnesia in 650 grammes 
of water fully charged with carbonic acid, that is to say, 
containing 1 gramme in 32 of liquid. 

Podophyllin.— This is what the English call vegetable 
calomel, because of its cholagogue action. It is a good 
laxative, especially when combined with belladonna. It 



CONSTIPATION. 175 

is best given in pills containing -1- grain each of podo- 
phyllin and of extract of belladonna. From 1 to 3 pills 
are taken at bedtime, 1 the first day, 2 the next if no lax- 
ative effect has been produced, and, if necessary, 3 on the 
following day. Once an action has been obtained, we 
must return to 1 pill and recommence the series if need be. 

Belladonna, which we have just mentioned in combina- 
tion with podophyllin, is a laxative by itself. Trousseau 
recommended it very highly, giving it in gradually in- 
creasing doses of from ■§- to 1 grain. This remedy is espe- 
cially indicated in cases in which there is severe colic as- 
sociated with constipation. 

Cascara sagrada. — This is an excellent laxative, which 
has the advantage of seldom producing colic, and which 
may be continued for a long time without any ill effects. 
The bark is given in powders of 1 grains each, one powder 
at bedtime or one morning and evening, if that does not 
suffice. In cases of atonic d} x spepsia with diminished 
acidity, it will be useful to combine a little magnesia with 
the cascara, for we know that alkalies in small dose in- 
crease the secretion of lrydrochloric acid. A fluid extract 
is sometimes employed instead of the powder of the bark. 

Rhamnus frangula. — Buckthorn, which is not used in 
France, is said to be an excellent laxative, which never 
causes griping. It is employed in Germany in the form 
of a decoction of 20 to 30 grammes to the litre. The pow- 
dered bark may also be given in doses of 15 to 20 grains 
at bedtime. 

Tamarind. — The pulp of the fruit of tamarindus indica 
is possessed of laxative properties ; it is given in confection 
in doses of 5 to 12 drachms (in somewhat smaller dose if a 
laxative action only is desired), or in an infusion containing 
5 drachms to the quart. It is found in the shops in the 
shape of a confection, which is a convenient form for ad- 
ministration. Occasionally, though not often, it produces 
colicky pains. 

Rhubarb is purgative in doses of 15 to 60 grains, laxa- 
tive in smaller doses. When given in small quantity it is 



176 DISEASES OF THE STOMACH AND INTESTINE. 

reputed to be a stomachic and is given at the beginning of 
a meal, alone or in combination with other powders such as 
cinchona or calumba. It would be better, however, to give 
it after eating in divided doses at intervals of half an hour. 

One may also for the same purpose prescribe the wine 
of rhubarb, alone or with the addition of from 5 to 15 drops 
of tincture of ijDecac, in cases of atonic dyspepsia with 
flatulence and constipation. Rhubarb would be an excellent 
laxative if it had not the disadvantage of frequently caus- 
ing griping pains. 

Manna. — This is a mild laxative much employed in the 
case of children. It may be given to them in doses of 5 
to 10 drachms dissolved in water or milk; for adults larger 
doses up to 3 ounces are necessary. When it is desired to 
dissolve it in milk or water the liquid must be hot. 

Senna. — This drug was formerly much more employed 
than it is at present, for it entered into the composition of 
a great number of purgative potions and enemata. It often 
gives rise to griping pains, but this effect is less frequent lv 
seenwhen an alcoholic extract is employed. All purgative 
teas have senna as their basis. The following is the for- 
mula of the purgative species (species laxantes) as given 
in the French Codex : 

R Senna Leaves, ..... 2.0 grammes. 

Elder flowers, 1.0 

Green anise seed, . . . .1.0 " 

Fennel seed, . . . . .0. 5 " 

Bitarl rate <>r potassium, . . 0.5 " 
M. Sig. To make a cup of infusion. 

The purgative draught of the Hospital Saint-Louis, often 
pre scribed by Hardy, is said to be a good preparation. It 
is made by infusing 2 drachms each of senna and viola 
tricolor in a quart of boiling water ; at the end of an hour 
the infusion is strained and sweetened with honey. The 
dose is a large glassful taken in the morning. Coffee dis- 
guises very well the taste of senna, so that the latter may 
be infused at the same time with the former, making a pur- 
gative coffee. 



CONSTIPATION. 177 

Scammony. — This is a drastic purgative which causes 
pretty severe griping pains. It enters in small porprotion, 
however, in the composition of a number of laxative prep- 
arations. The powder may be given alone in milk, the 
ordinary purgative dose being from 7 to 8 grains. 

Aloes. — This forms the basis of a large number of lax- 
ative elixirs and pills. Its special advantage is that it 
acts in small dose and lends itself readily to administration 
in pill form. It is apt to induce a swelling of hemorrhoidal 
tumors, a property that is sometimes taken advantage of 
to bring back a bleeding in the piles when certain conges- 
tions of other parts seem to be due to the suppression of 
this flow. The drug also causes a congestion of the pelvic 
organs, and this fact offers a contra-indication to its em- 
ployment when an}^ inflammation of these organs exists, 
as, for example, when an old man is suffering from chronic 
prostatitis. The laxative dose is from 1 to 3 grains. The 
drug acts rather slowly, its effects being produced at the 
end of from ten to twenty hours. It is not apt to cause 
any severe griping pains. With larger doses, 6 to 12 
grains, a marked purgative effect is obtained. Aloes is 
reputed to be a stomachic in small doses*, hence its use is 
almost traditional in dyspepsia. It is administered usu- 
ally in the form of pills, many of which have received 
special names. The pilulce ante cibum contain each 2 
grains of pulverized aloes and 1 grain of extract of cin- 
chona; the dose is 1 or 2 pills at the beginning of a meal. 
Anderson' s pills contain 2 grains each of aloes and gam- 
boge ; the . latter is a drastic purge and the pills therefore 
are very active. Soap is a good vehicle for aloes. Fifteen 
grains each of aloes and medicinal soap may be mixed and 
made into ten pills. The following formula, devised by 
Lutz, is an excellent one and we can recommend it : 

1$ Aloes, 

Scammony, 

Jalap, . . . . . . . aa gr. xv. 

Glycerin, ttt, viij. 

Solution of caustic soda (29 per cent) , ttj, xv. 

M. et ft. pil. no. 20-25. Sig. One pill at bedtime: 
12 



178 DISEASES OF THE STOMACH AXD INTESTINE. 

We know of a number of individuals who have taken 
these pills for several years with great satisfaction and 
without experiencing any inconvenience from this long- 
continued use. 

Castor oil, in teaspoonful or half -teaspoonful doses, is 
one of the best laxatives that we have. It may be taken 
for a long time without inconvenience, and does not pro- 
duce secondary constipation. Its disagreeable taste may 
be masked by black coffee, orange juice, or black currant 
brandy. It may also be taken in capsules, a number of 
which are found in the market, which offer a very con- 
venient mode of administration for those who can swallow 
them. 

Special Clinical Forms of Constipation.— Alter hav- 
ing passed in review the different hygienic, mechanical, 
and medicinal measures which can be employed in com- 
bating this condition, we shall now indicate what special 
means are best adapted to the relief of the different forms 
met with clinically. We shall study constipation, (1) due 
to faulty hygiene, (2) in infants, (3) in cases of gastro- 
intestinal dyspepsia, (4) in cases of enteroptosis and obe- 
sity, and (5) in the aged. 

Constipation Caused by Faulty Hygiene. — This is 
the form so frequently brought about by the abuse of ni- 
trogenous food and the neglect of exercise, and it is by 
measures directed against these etiological factors that we 
must combat the condition. The patients must be made 
to eat more green vegetables and stewed fruits of various 
kinds, stewed apples and prunes. Rye bread is useful in 
some cases. We may also advise the employment of lin- 
seed or psyllium, which acts in the same way as those 
vegetable substances which leave a considerable undigested 
residue. In cases of this kind we may give salines or al< >es 
in moderate doses and cautiously. Physical exercise in 
the open air and gymnastics will naturally be among the 
means resorted to to overcome the constipation due to a 
neglect of these measures. 

When all these fail we must have recourse to enemas 



CONSTIPATION. 179 

and mild laxatives, such as cascara sagrada, magnesia, 
tamarind, rhamnus, or Lutz's pills above mentioned. The 
medicinal treatment should be employed only as long as is 
absolutely necessary and must be replaced as soon as pos- 
sible by hygienic measures. In very obstinate cases, es- 
pecially among the neurotic, massage and electricity will 
be useful as aids to the action of laxatives. Castor oil is 
here particularly to be recommended. Saline purgatives 
should be employed only temporarily when there are signs 
of acute indigestion or auto-intoxication, with the object 
of obtaining a sort of antisepsis by a thorough sweeping 
out of the intestinal tract. 

Constipation in Children. — Young children naturally 
never think of going to stool unless they are compelled to 
do so, and as the desire gradually grows less they become 
constipated. Nurses have some simple remedies for re- 
awakening this blunted reflex. One of these is to intro- 
duce into the anus any solid body, such as a little stem of 
parsley or chervil, which usually speedily causes a move- 
ment. Sometimes it will be necessary to employ small in- 
jections of pure water, glycerin, or oil emulsion. 

The disorder is quite common also in older children, es- 
pecially those living in the city, and sometimes becomes 
so inveterate as to lead to attacks of muco-membranous 
enteritis with pseudo-diarrhceic discharges. It is this di- 
arrhoea that the family and even the physician at times 
fear and attack, when in reality they should turn their at- 
tention rather to the underlying constipation. It is well, 
therefore, to be on our guard when we discover mucus in 
the stools of children. The treatment consists in the use 
of manna, magnesia, or castor oil in small doses. Of 
course we must not neglect hygienic measures. In cases 
of intercurrent diarrhoea, with or without the appearance 
of mucus in the stools, we may advantageously give calo- 
mel in doses of H to 3 grains in honey. The calomel should 
be repeated only at rather long intervals, and great caution 
should be observed in its use. 

Gastro- Intestinal Dyspepsi a.— Constipation is fre- 



180 DISEASES OF THE STOMACH AND INTESTINE. 

quent in the various forms of -dyspepsia. The therapeutic 
indications are, in a general fashion, the same as those 
which we have indicated in the section on the results of a 
faulty hygiene, yet there are some special points to be con- 
sidered. In cases of hypersecretion of hydrochloric acid, 
we must reduce to a minimum the irritation of the stomach, 
hence aloes, scammony, and senna are hardly suitable. 
Neither can we permit these patients to eat a large quantity 
of green vegetables because of the gastric stagnation which 
exists or tends to exist, and also because this alimentary 
residue helps to increase still more the secretion of acid, 
Patients with dilatation with permanent stasis ought not, 
for the same reason, to take given vegetables or inert seeds 
such as psyllium. Magnesia in rather large dose does 
good service in cases of this nature; in small doses it is 
more suitable for patients with diminished acidity, since 
alkalies in small quantities stimulate the secretion of hy- 
drochloric acid. Hay em holds that the long-continued use 
of sulphate of soda reduces or even suppresses altogether 
the production of hydrochloric acid; another reason why 
the use of purgative waters, especially in the case of dys- 
peptics, should not be abused. 

Enteroptosis and Obesity. — Glenard recommends the 
purgative saline waters in cases of enteroptosis, for in 
these patients a condition of more or less marked abdomi- 
nal plethora, such as is found in the obese, is of ten present. 
Mineral water cures are much in vogue at Brides in Savoy, 
and at Tarasp-Schuls, Marienbad, Carlsbad, and Elster in 
Germany. 1 

Constipation in Old People. — The aged are very sub- 

1 Brides water contains per litre 9.30 grammes of magnesia, 5.06 
of sulphate of soda, and 0.83 of chloride of magnesium. It is laxa- 
tive in doses of one glass, and purgative in doses of three or four 
glasses. 

Chatel-Guyon water, which may be used in similar cases, owes 
its laxative properties to chloride of magnesium (1.22 grammes per 
litre) and to bicarbonate of magnesium (0.42 per litre). Four or 
five glasses a day are needed to produce a laxative effect, and it is 



CONSTIPATION. 181 

ject to this trouble. It is in them, especially in women, 
that we so often find collections of scybalous masses in the 
colon. In consequence of the atrophy of the muscular 
coats of the intestine the condition may end in actual ob- 
struction (Thibierge) . We shall refer to this in another 
place. When hygienic measures alone are insufficient we 
must prescribe injections, suppositories, castor oil in small 
doses, and occasionally saline purgatives. 

Complications. — Constipation due to intestinal atony, 
which we have had especially in view, may be accompanied 
by complications of various kinds. The presence of more 
or less indurated masses of fasces, and the mechanical ob- 
stacle which they offer to the passage of the contents of 
the bowel, may induce further atony and gastro-intestinal 
flatulence. There is little danger of auto-intoxication 
when the faecal matters are hard, as there is then little ab- 
sorption of toxic substances. But attacks of diarrhoea of 
inflammatory origin not infrequently succeed the consti- 
pation, and we then see symptoms of acute indigestion, 
due no doubt to auto-intoxication. There are certain other 
complications arising from mechanical causes ; the indu- 
rated matters provoke by their presence a superficial in- 
flammation of the mucous membrane, and we get symp- 
toms of chronic colitis and of muco-membranous enteritis. 
The fsecal masses have a tendency to accumulate especially 
in the caecum and sigmoid flexure, and the accidents which 
they cause vary according to the anatomical conformation 

therefore not suited to cases in which there is dilatation of the 
stomach . 

In the waters of Marienbad, a spa particularly recommended for 
the cure of obesity, we find 5 grammes of sulphate of soda and 0. 66 
of sulphate of magnesia per litre. One litre contains nearly 10 
grammes of mineral substances. 

Carlsbad water contains 2. 40 grammes of sulphate of soda, 0. 186 
of sulphate of potassa, and 0. 16 of carbonate of magnesia. The dose 
is two or three glasses a day (300 to 450 grammes) . 

We should remark that these waters are used rather for the cure 
of obesity than for that of constipation in the obese. 



182 DISEASES OF THE STOMACH AND INTESTINE. 

and the physiological action of these segments of the in- 
testine. Recent researches, and more particularly laparat- 
omies on the living subject, have shown the rarity of 
typhlitis from stercoral engorgement of the caecum and the 
frequency of ulcerative appendicitis; it has even been 
doubted whether such a thing as typhlitis from caecal im- 
paction exists. Nevertheless appendicitis is an accident 
occurring almost exclusively in sufferers from habitual 
constipation, and the most frequent cause of inflammation 
of the vermiform appendix is the presence of a little mass 
of faecal matter entering from the caecum. 

The accumulation of scybala in the sigmoid flexure leads 
to dilatation; this sometimes gives rise to an insurmount- 
able obstacle and to intestinal obstruction. It happens 
occasionally that the sigmoid flexure thus distended by 
faecal matter falls forward, turning on its axis, and so pro- 
duces an occlusion by torsion. 

The repeated straining at stool necessitated by the fact 
of constipation, the hindrance to the venous circulation of 
the intestine, and the inflammatory irritation caused by 
the contact and more or less violent passage of hardened 
faeces are causes which lead to the production of hemor- 
rhoids, and then the latter, forming part of a vicious circle, 
increase the constipation by offering an obstacle to the 
evacuation of the rectum. Finally, the passage of these 
large indurated masses causes not infrequently erosions 
and painful Assures of the amis; the latter often coexist 
with hemorrhoids. Of these complications, intestinal ob- 
struction and occlusion will he studied in a special chap- 
ter, as will also typhlitis and appendicitis. The treatment 
of auto-intoxication and acute indigestion will be given 
in the chapter on intestinal antisepsis. Fissure of the 
anus calls for surgical treatment. We have then in this 
place to concern ourselves only with muco-membranous 
enteritis and the medical treatment of hemorrhoids. 

Muco-membranous enteritis is an affection which has 
been recognized for a considerable period but is even yet 
insufficiently studied ; it is the glutinous diarrhoea of Van 



CONSTIPATION. 183 

Swieten. 1 In the older writings (Morgagni, Fernel), ob- 
servations are made of cases which were evidently muco- 
membranous enteritis. More recently attention has been 
specially drawn to the affection by articles and works of 
numerous writers, French, English, and American. 2 

The most complete clinical history of the disease that 
we possess is found in the work on " Gastro- Intestinal Dys- 
pepsia," by Germain See (1883, p. 223). At the beginning 
and in very mild cases, the affection is characterized sim- 
ply by the appearance in the stools of sufferers from con- 
stipation of transparent glairy mucus, coming in greatest 
abundance with the last portion of the evacuation. In 
other cases the mucus collects in little masses looking like 
frog's spawn or pieces of soft-boiled white of egg. Some- 
times there is a whitish coating evenly spread over the 
surface of the faeces, or there may here and there be irreg- 
ular whitish or membranous fragments. These may sim- 
ulate tape- worm, and this error has not infrequently been 
made, not only by the patients, but also by physicians. 
More rarely there are little tubular pieces, which are some- 
times mistaken for sphacelated and detached fragments of 
the mucous membrane or for pieces of croupous pseudo- 
membrane. 

This is the form which muco-membranous enteritis takes 
outside of the acute attacks which we shall describe pres- 
ently. Microscopical examination has shown the presence 
in these glutinous or membranous matters of mucus, epi- 
thelial debris, an enormous quantity of microbes, especially 
of the bacillus coli, but very little fibrinous albuminoid 

1 Glutinous diarrhoea (Van Swieten) ; glairy enteritis (Nonat) ; 
tubular diarrhoea (Good) ; mucous affection of the intestine (White- 
head) ; membranous enteritis (Da Costa) ; membranous affection of 
the intestine (Gross) ; painful affection of the intestine (Powell) ; 
intestinal croup (Clemens) ; herpedite exfoliatrice (Gigot-Suard) ; 
mucous colic (Nothnagel) ; fibrinous diarrhoea (Granthaus) ; inter- 
stitial enteritis (Wanebroucq) .— G. Lyon, Gazette des Hopitaux, p. 
493, 1889. 

2 A bibliography will be found in the "Medical and Surgical 
History of the War of the Rebellion " (United States) . 



184 DISEASES OF THE STOMACH AND INTESTINE. 

material. It is, therefore, a superficial catarrhal inflam- 
mation of the large intestine, unassociated with any deep 
lesion, at least in recent cases. It is probable that the 
desiccation of the mucous secretion by resorption of its 
water gives to it a glutinous and then a membranous as- 
pect. However, there may be a more deeply seated in- 
flammation, which may even lead to ulceration, becoming 
then an interstitial enteritis. Wanebroucq has seen cases 
of this kind, but the name interstitial enteritis certainly 
applies only to a small number of severe and inveterate 
cases of mueo-raembranous colitis. 

It is probable that muco-membranous enteritis is not a 
morbid entity, but that it may depend upon various etio- 
logical factors. However this may be, it occurs frequently 
as a complication of constipation, and that is what concerns 
us here. Patients with this affection often suffer from 
very intense colicky pains in the region of the colon. 
These pains frequently assume the form of true crises, en- 
teralgia, which have occasionally been mistaken for hepat- 
ic colic. There may be acute attacks which modify greatly 
the aspect of the disease, coming on after a prolonged 
period of constipation. These dysenteriform crises, which 
have been well described byLasegue, nave not infrequently 
been taken forsporadic dysentery; there are frequent pain- 
ful evacuations, tenesmus, bloody discharges, in fact noth- 
ing is wanting to make the resemblance complete. Be- 
tween these severe dysenteriform crises and constipation 
with mucous discharges, there are many intermediate 
forms; in children especially the attacks of diarrhoea fol- 
lowing constipation are quite frequently accompanied by 
slight tenesmus, and the expulsion of a little bloody mucus. 
Occasionally accompanying these severe intestinal pains 
and the diarrhoea, there is an elevation of temperature 
which may arouse a suspicion of typhoid fever. This is 
the result of the breaking up of matters rich in toxic sub- 
stances and in which bacteria swarm ; we are unable to 
say whether there is simply a poisoning of the system by 
absorption of chemical substances or whether there is an 



CONSTIPATION. 185 

actual penetration of bacilli, of the bacillus coli perhaps, 
through the eroded mucous membrane, but there can be 
no doubt of the infectious nature of these phenomena and 
of their origin in the colon. 

In the milder forms when there is simply the presence 
of a small quantity of mucus, the treatment is that of the 
constipation. We must not forget that there may be at 
the same time hypersecretion of hydrochloric acid, mova- 
ble kidney, or neurasthenia, and that the treatment must 
therefore be directed against these affections, if they exist, 
as well as against the constipation. The best laxative in 
these conditions is castor oil given in small doses every 
morning. Injections are also useful. Muco-membranous 
enteritis is often treated, at Plombieres especially, by as- 
cending douches, and the results obtained are excellent in 
many cases. However, as Malibran 1 very justly remarks, 
they must not be administered during acute attacks. This 
writer combines ascending douches with enemata given 
at bedtime and retained during the night and with abdom- 
inal massage, especially when there are hard masses of 
faeces in the intestine. Frequently the bowel does not rid 
itself of these retained scybala until the ascending douches 
have been administered daily for some time. In cases of 
moderate severity much good sometimes follows a course 
of purgative mineral waters, but we must be sure that the 
condition of the stomach is not such as to offer a contra- 
indication to this form of treatment. When the pain is 
very severe we must resort to hot applications, hot baths, 
or belladonna ; opium and morphine have the disadvantage 
of increasing the constipation. 

In cases of profuse diarrhceic discharges with typhoid 
symptoms, it will be well to give a purge. To this end 
we may employ any of the salines or purgative mineral 
waters, but, in children especialty, the remedy to be pre- 
ferred is calomel, which possesses antiseptic properties. 

Lavage of the intestine may be accomplished by means 
of enteroclysis. For this purpose all that is necessary is 
1 "L'Atonie Intestinale et ses Complications." 



186 



DISEASES OF THE STOMACH AND INTESTINE. 



to attach a rubber tube to a reservoir or a simple funnel, 
the lower extremity of the tube being provided with a soft 
rubber catheter or oesophageal sound. The bowel may 
then be washed out with boiled or liaphtholated water. In 




Fig. 4.— Galante'S Apparatus for Enteroelysis. 

order to insure deep penetration of the liquid, Le Gendre 
advises that the injection be made with the patient lying 
on his back with the hips slightly elevated ; after as great 
a quantity of water as possible has been injected the pa- 
tient turns over on his right side, and then it will be found 
that a still larger amount can be passed into the intestine. 



CONSTIPATION. 187 

This is because the change of position allows the fluid to 
pass around the left angle of the colon and enter the trans- 
verse portion. 

Revilliod has recently proposed the following plan of 
treatment for muco-membranous enteritis. He first orders 
a very large enema to be given in the way Le Gendre ad- 
vises, adding to it some castor oil or ipecac in order to ob- 
tain a thorough clearing out of the intestine. If neces- 
sary, a second injection of borated water may be given. 
After that he administers an injection of 2^ drachms each 
of subnitrate and of salicylate of bismuth in 1 pint of mu- 
cilage of quince seed ; this is to be retained, if possible, for 
twenty-four hours, the patient remaining in bed. If this 
entire amount cannot be retained a smaller quantity is 
given. It has been found that the bismuth in this mix- 
ture is not entirely expelled until after several days. This 
mode of treatment is said to have sometimes cured muco- 
membranous enteritis, and good results are said to have 
been obtained by it in dysentery and in all cases in which 
an ulceration of the large intestine exists. 1 

Benzo-naphthol is indicated whenever intestinal anti- 
sepsis is desired; it is given in7-grain doses to the amount 
of about a drachm a day. 

In the treatment of membranous enteritis the patient 
should be placed in the most favorable hygienic conditions 
possible, and he should avoid exposure to cold, especially 
to chilling of the abdomen. Care should be taken not to 
overload the stomach or to irritate it with rich or spicy 
food. 

Hemorrhoids. — This trouble is a frequent complication 
of constipation, and it would seem that the constitution 
which predisposes to the one condition predisposes also to 
the other. Some writers look upon active congestion of 
the rectal veins as the principal cause of piles, while others 
regard the affection as due to a mechanical stasis which is 
favored by the anatomical disposition of the hemorrhoidal 

1 Revue Medicale de la Suisse Romande, and Bulletin Medical, 
Jan. 29th, 1893. 



188 DISEASES OF THE STOMACH AND INTESTINE. 

veins and also by the efforts at defecation to which these 
patients are forced. It is probable that all these elements 
enter into the pathogenesis of rectal varices. Quenu thinks 
that the elasticity of the veins is previously compromised 
by a chronic phlebitis; this phlebitis would explain the 
persistence of the venous dilatations as soon as they have 
attained a certain degree and have lasted for a certain time. 

Hemorrhoids are internal or external according as they 
are developed above or below the anal sphincter ; the ex- 
ternal are alone visible on ordinary inspection. They ma}" 
be more or less voluminous and are, like the internal ones, 
subject to acute congestive attacks ; tiny are then turgid 
and bluish in color. When they have existed for some 
time they become thickened, withered, and look as if cov- 
ered with skin, assuming, in a word, the appearance of 
tiheficus of the older writers. 

Internal hemorrhoids are appreciable only to the touch, 
except at such times as they arc extruded through the anal 
sphincter. The latter occurs when they arc swollen and 
pushed out by descending fa?cal masses. They may then 
become strangulated and can he reduced only with great 
difficulty. Sometimes t hoy become the seal of a more or 
less abundant hemorrhage, which takes place usually after 
a movement. The irritated rectal mucous membrane often 
exudes a leucorrhoeic discharge. There may also be pro- 
duced ulcerations and very painful fissures. 

The 1 symptoms consist in mild cases of a feeling of weight 
at the anus, increased difficulty in defecation, and tenes- 
mus; in more severe cases there is acute pain with stran- 
gulation and ulceration of the mucous membrane. When 
the tumors become strangulated they may ulcerate, be- 
come inflamed and the seat of abscesses, and the phlebitis 
may cause secondarily abscess of the liver, pysemia, etc. 
The hemorrhages may be so frequent and abundant as to 
cause anaemia and debility. 

Medical treatment usually suffices when the condition is 
not very marked, when the congestion is slight and hem- 
orrhage is not profuse, and when, in the case of extruded 



CONSTIPATION. 189 

internal piles, reduction is easy ; when these conditions are 
reversed, when serious inflammation threatens, and when 
the loss of blood is considerable, we must resort to surgical 
measures. We are concerned here with the medical treat- 
ment only. 

We must, before all else, overcome the constipation, 
which, if it is not the primary cause, tends at least to ex- 
aggerate the trouble. We should avoid the use of aloes 
and of the drastic purgatives which cause congestion of 
the pelvic organs. In the case of moderate tenesmus and 
not very abundant hemorrhage we may give small injec- 
tions of cold water several times a day. It is a good plan 
to give a cold enema after each movement. If the tumes- 
cence is more marked and the tumor is reducible with diffi- 
culty, applications of very hot water, made by means of 
compresses or of a small sponge, may be of service. 
Sometimes good results follow the direction of steam from 
the nozzle of a kettle against the tumors. We may also 
give hot baths, in a tub in preference to sitz baths, or use 
sprays of borated or carbolated water. Hot applications 
are much preferable to cold ones, although the latter are 
often recommended. Nelaton advised sufferers from this 
condition to go to the closet in the evening rather than in 
the morning, as the recumbent position favors the reduc- 
tion of the hemorrhoidal tumors. 

When there is prolapse and the tumors are irreducible 
by ordinary means we may proceed in the following way : 
The patient lying on the side, the operator introduces the 
index finger of the left hand, smeared, with borated or 
iodoform -vaselin, the entire region having been previ- 
ously washed with boiled or hot borated water ; then with 
the right hand taxis is made, the tumors being slidden 
along the index finger which serves as a guide. It has 
been advised, in cases in which these measures fail, to ap- 
ply leeches or to prick the hemorrhoids with a lancet ; but 
these are dangerous procedures and may cause inflamma- 
tion and phlebitis. Leech bites where antisepsis is im- 
possible are particularly dangerous. It would be much 



190 DISEASES OF THE STOMACH AND INTESTINE. 

better to resort at once to surgical methods, especially to 
forcible dilatation of the anus. 

Certain drugs have the reputation of reducing the hem- 
orrhoidal congestion; among these are hamamelis, capsi- 
cum, and ergot, but the latter ought not, in our opinion, 
to be used. Capsicum annuum (red pepper) is given in 
pill form in doses of from 12 to 30 grains a day, or in 
aqueous extract in doses of from 4 to grains morning and 
evening. Hamamelis virginica (witch hazel), which is at 
least harmless, is said by some to cure all forms of varices 
including hemorrhoids. It may be given in tincture in 
doses of 5 to 10 drops three times a day. In America the 
most commonly employed form is the fluid extract given in 
doses of 1 to 2 drachms. A solid extract, improperly called 
hamamelin, is used in doses of 1 grain in pill form (Sou- 
lier). Milfoil and ranunculus ficaria (pilewort) have also 
been recommended. 

Hemorrhage is treated by cold injections and the appli- 
cation of ice, or by tampons of iodoform gauze or cotton. 
Care must be taken to see that the blood does not escape 
into the rectum without appearing externally. 1 Excep- 
tionally the hemorrhage is very profuse. In a case of this 
kind Landowski succeeded in arresting the hemorrhage' 
by plunging the patient into a bath with a temperature of 
95°, raised to 1 L3° F., the anus being held open by a spec- 
ulum. 

The pain may be relieved by suppositories of belladonna, 
opium, morphine, or hyoscyamus, to which astringents, 
such as tannin or rhatany, or antiseptics, such as iodo- 
form, salol, or antipyrin, may be added. Reclus recom- 
mends very highly the application of hot water (113° to 
12-2° F. ) and the introduction into the anus of little pledg- 
ets of absorbent cotton wet with a solution of cocaine 
(1:50). This is especially useful when the hemorrhoids 
are swollen and painful. When the pain is very severe 
and tenesmus, due to erosions or fissures, is intense, for- 

1 Ozenne : "Hemorrhoides, " Bibliotheque Charcot -Debove. 

2 Landowski : Revue de Chirurgie, p. 500, 1881. 



CONSTIPATION. 101 

cible dilatation of the sphincter will be the best remedy . It 
does not cure the disease, but it gives great relief. 

In cases of leucorrhceic discharge and of superficial in- 
flammation of the skin or mucous membrane of the anal 
orifice, astringent ointments are useful ; such are tannin, 
15 to 30 grains to the ounce of vaselin, glycerole of tan- 
nin, oxide of zinc ointment (1 : 10), etc. Brinley applies 
calomel to inflamed or bleeding piles ; Reissmann 1 touches 
them with a solution of iodine in glycerin. He first uses 
a weak solution (iodine, 3 grains, iodide of potassium, 30 
grains, and glycerin, 1 ounce), and then a stronger one 
(iodine, 15 grains, iodide of potassium, 1 drachm, and 
glycerin, 1 ounce). In response to these applications it 
is said that the hemorrhoids rapidly diminish in volume, 
the ulcers heal, and a cure of even the most severe cases 
is obtained within two or three weeks. But we may be 
permitted to question the certainty of these results. 

1 Wiener medizinische Presse, No. 12, 1892. Quoted by Ozenne. 



CHAPTER VIII. 
DIARRHCEA. 

We shall not attempt to present a complete description 
of diarrhoea in this chapter, but shall limit ourselves to a 
consideration of the therapeutical indications present in 
this condition. What we shall have to say, however, of 
the principles of treatment of diarrhoea as a symptom will 
find its application when we come to speak of the special 
forms in subsequent chapters. 

Definition. — Diarrhoea consists essentially in the elim- 
ination by the intestine of a quantity of water much 
greater than normal. This water comes from the small 
intestine. When there is a discharge of fluid exuded from 
the walls of the large we have to do with a false diarrhoea, 
as in certain forms of muco-membranous colitis and in 
dysentery. The fluid may be what is taken in by the 
mouth, being eliminated in consequence of an excessive 
peristaltic action of the stomach and intestine, or it may 
be the result of an exaggerated secretion from the diges- 
tive tube or its adnexa. The water thus passed out may 
carry with it a very complex mixture of substances of di- 
verse nature and origin. The predominance of one of these 
substances, the bile for example, may give to the diarrhoea 
a special character; itis thusthat certain semeiological va- 
rieties are distinguished. We will pass rapidly in review 
the principal etiological and pathogenic factors, for though 
we shall not dwell long on this point, it is impossible to 
make a general study of the treatment if we have not a 
sufficient idea of the causes and mechanism of this patho- 
logical phenomenon. 

Etiology. — Speaking broadly there are four main causes 
of the disease, viz. : 1, external forces of a physical or me- 

192 



DIARRHCEA. 193 

chanical order, such as traumatism, heat, cold, etc. ; 2, in- 
fection;. 3, intoxications; 4, the mode of vital reaction pe- 
culiar to the special category of living beings, and above 
all the morbid excitability of the nervous system (arthri- 
tism, the neurotic condition). Frequently several of these 
forces combine their action in such a way that, in any 
particular case, the etiological elements are seen to be very 
complex ; and in all cases we have to take into account the 
special mode of reaction of the individual in the presence 
of an}' particular morbid cause. 

We must learn to recognize the nature of these causes 
and the importance of their role in each individual case, 
and also how best to combat if not entirely to suppress 
them. It is a truism that we must suppress the cause of 
the disease, but it is fully as important, from a point of 
view of therapeutics, to discover what the mechanism 
of diarrhoea is. And this leads us up to a much-debated 
question, viz. , what is the mechanism of purgation ? Some 
believe that there is an exaggerated secretion of the intes- 
tinal fluids, while others hold that the increased peristaltic 
action of the bowel hurries along the entire contents, se- 
cretions, ingested fluids, etc., allowing no time for absorp- 
tion or for the gradual desiccation of the faeces. This 
would be a very simple mechanism. The partisans of the 
theory of increased secretion explain it in different ways : 
some hold that there is an actual catarrhal inflammation 
of the mucous membrane, others that there is a congestion 
of the vessels through vaso-motor reflex, while others still 
look upon it as a simple exosmosis. It is possible that 
there is more or less truth in all these explanations, and 
the question is to determine the predominating factor in 
the particular case under observation. There appears often 
to be a hypersecretion joined with augmented peristalsis. 
Excessive movement, vaso-motor disturbance, these are 
the two fundamental elements. It is probable that the first 
finds expression in the colicky pains, and these pains there- 
fore offer an important indication for treatment. They are 
to be overcome by sedatives, by opium especially. 
13 



194 DISEASES OF THE STOMACH AND INTESTINE. 

Let us see how these general causes act in producing 
diarrhoea, and what the mechanism is by which they pro- 
voke it; that will furnish us with the indications for treat- 
ment. Among the physical causes cold is the most im- 
portant ; it acts in a reflex way by stimulating either the 
movement of the intestine or its secretion. It acts the 
more readily as the personal susceptibility is greater, as 
its effects are most marked in the neurotic and those of the 
rheumatic diathesis whom Landouz so justly calls the 
neuro-arthritic. Certain persons also have a special pre- 
disposition to diarrhoea, having, as it were, a sensitive in- 
testine, and in them diarrhoea follows any exposure to cold 
and even results from any unusual mental emotion. We 
must take this personal equation into account. 

In the section on purgatives we have said all that is 
necessary concerning the toxic causes of diarrhoea, and 
we will only add here that, in addition to the toxic mat- 
ter^ of infectious origin, there are also purgative substances 
furnished by the organism itself. The bile, for example, 
has been called a physiological laxative, and any hyper- 
secretion of this fluid is almost of necessity accompanied 
by diarrhoea. Looseness of the bowels is also not uncom- 
mon in uraemia and is due apparently to an elimination by 
the intestine of auto- toxic substances; it is therefore a con- 
dition which ought not to be thoughtlessly arrested. 

The mechanism by which infection produces a diarrhoea 
is certainly very complex. In this condition we have to 
distinguish two greal classes of phenomena: 1. The infec- 
tious agent remains localized in the intestine, and causes 
irritation and inflammation cither directly or by the toxic 
products which result from its presence; 2. The infectious 
aucnt itself penetrates into the organism and gives rise to 
a general infection, such as we see in typhoid fever. 

In the first case the toxic substances produced by the 
infectious agent or under its influence may act almost ex- 
clusive!}' upon the intestine, or else, if they have been ab- 
sorbed and have escaped the destructive action of the liver, 
they occasion general symptoms of a purely toxic nature. 



DIARRHOEA. 195 

These are the cases which we designate as acute indiges- 
tion. The indication in these conditions is to favor the 
elimination by the rectum of the poison remaining in the 
intestine, to destroy the zymotic agent which has elabo- 
rated it, and to bring about the expulsion through the kid- 
neys of that which has already been absorbed into the sys- 
tem. This will suffice to effect a cure provided that there 
is not too severe a degree of inflammation of the intestine 
present. 

The same indications are present in the second case, but 
here another element comes in. The pathogenic bacteria 
continue their evolution in the organism, and it is upon 
their presence that the course and duration of the disease 
especially depend; the intestinal phenomena pass into the 
second rank of importance. Typhoid fever is a good ex- 
ample of diseases of this class. 

In any case of infectious diarrhoea we must aim to secure 
the elimination and destruction of the morbific agent ; its 
destruction, or at least the reduction of its injurious effects 
to a minimum, is precisely the object of intestinal antisep- 
sis, to the study of which we shall devote a special chap- 
ter. It is for this reason that we so often combine anti- 
septics with the other remedies directed solely to a slowing 
of peristalsis or a drying up of the secretions of the bowel. 

The neuropathic element may of itself produce diarrhoea, 
usually transitory, such as we see often as a result of strong 
emotions or great fear. This nervous diarrhoea may also 
be persistent, as when it occurs in patients suffering from 
some lesion of the spinal cord, tabes for example, or from 
Basedow's disease, neurasthenia, hysteria, etc. The gen- 
eral neuropathic element often enters also into the causation 
of other varieties of diarrhoea. 

We have hitherto considered only the physiological and 
pathogenic element, but we must not forget that there may 
also be added an anatomical element, that acute or chronic 
enteritis may arise according as the causes are more or 
less persistent. The enteritis becomes then itself a cause 
of the diarrhoea, and after overcoming the original cause 



196 DISEASES OF THE STOMACH AXD IXTESTIXE. 

we shall still have to fight against the lesion of the intes- 
tine remaining. 

But this is not all, and in order to attain success in our 
fight against the disease we must be familiar with the in- 
jurious consequences that it may entail upon the organism. 
By reason of a persistent and copious diarrhoea the food is 
rushed through the alimentary canal without being di- 
gested, and there results a true state of inanition which 
can only be averted b} T an appropriate diet. When the 
flux is very abundant the elimination of large quantities 
of water may be a danger, giving rise to choleraic phe- 
nomena, such as anuria, weak pulse, reduction of body 
temperature, and cyanosis. There may also be an element 
of auto-intoxication joined to this mechanical one, yet we 
should not lose from view the fact of this elimination of 
fluids and should do what lies in ourp >wer to supply the loss. 

Passing now to the remedial agents at our disposal for 
the treatment of diarrhoea, we shall study .successively : 1, 
diet; "2, medicines acting especially in the way of a re- 
duction of peristalsis: 3, drugs which diminish intestinal 
secretion; 4, intestinal antisepsis; and, 5, measures adapted 
to overcome the injurious effects of the excessive loss of 
fluids. 

1. Diet. — The genera] indication here is to reduce the 
mass of food in the intestine, and especially to remove as 
far as possible from the diet all those substances which 
leave a large indigestible residue to act as an irritant to 
the intestinal mucous membrane. We must prescribe a 
diet that contains a large amount of nourishment in small 
compass, and this excludes green vegetables at once. We 
should advise the taking of those articles which possess 
astringent properties and proscribe those which are laxa- 
tive in their action. In regard to these points there are 
often individual idiosyncrasies which w r e must inquire 
into and respect when learned. Finally, we must endeavor 
to prevent, as far as we can by means of appropriate food, 
intestinal fermentation and the further elaboration of tox- 
ines by the rood undergoing digestion. 



DIARRHOEA. 197 

When the diarrhoea is temporary and results from an 
acute indigestion, the indications are best fulfilled by re- 
stricting the diet, allowing, for example, only eggs, milk, 
soups, very little meat, and little in the way of drink. In 
all cases, of whatever nature, it is necessary to forbid 
highly seasoned food and strong cheese, which would carry 
into the intestine already formed toxic substances and pre- 
dispose to subsequent fermentation. Articles of diet which 
leave an abundant residue also favor the occurrence of 
fermentation. This is a subject closely related to intesti- 
nal antisepsis, of which we shall speak later. 

As a general rule only a limited amount of fluids should 
be permitted, but this is a rule not without important ex- 
ceptions. The diminution in the quantity of water in- 
gested is of no particular moment in cases of merely tem- 
porary diarrhoea. When the flux is excessive, as in 
choleriform diarrhoea, the thirst from which the patient 
suffers is sometimes intense. It will occasionally be use- 
ful to enforce an entire abstinence from food and to permit 
only a little pure water or lactic acid lemonade. This is 
the best way of preventing intestinal fermentation by 
withdrawing everything that may serve as a basis for this 
process. If the water or the lemonade is not retained and 
there is a tendency to collapse from excessive dehydration, 
we may have to replace artificially the fluid withdrawn 
from the circulation ; we shall return to this subject later. 

Milk may render great service in the treatment of many 
forms of diarrhoea. It is a complete aliment, liquid in 
form, and little liable to putrescent decomposition. We 
may, according to circumstances, prescribe a partial or 
an absolute milk diet, and sterilized milk often, especially 
in infants, gives better results than the natural fluid. 

Eggs are frequently employed, and rightly, for they 
afford a large amount of nourishment in small volume. 
Albuminous water may also be given as a beverage; its 
beneficial action, while not thoroughly understood, is nev- 
ertheless very real. 

Raw meat is of service in chronic diarrhoea, especially 



198 DISEASES OF THE STOMACH AND INTESTINE. 

in children. In its preparation, whether by mincing, 
scraping, or pounding, we remove all the indigestible por- 
tions. It may be taken in bouillon, with tapioca, or with 
jam; children take it readily when mixed with jam. 
Meat powder, with prepared chalk or bismuth, may also 
be used with advantage, especially in cases of phthisis. 

Among the astringent alimentary substances we may 
mention rice, quinces, and starch, which may be given in 
the form of decoction or by enema. Quinces enjoy a spe- 
cial reputation in this respect ; we may prepare a decoction 
of the seeds (i to 1 ounce in 2 pints of water), the good 
effects of which are due perhaps as much to the mucilage 
as to the tannin which it contains, or a syrup which may 
be given in doses of l£ to 3 ounces alone or employed to 
sweeten other more or less complex mixtures. The starch 
is given in decoction either by the mouth (3 to 5 teaspoon- 
fuls to the quart of water) or by enema (3 to 5 teaspoonsf uls 
to the pint). 

Peristaltic Sedatives. — These remedies are at the same 
time calmatives of pain, for the colic seems to be in effect 
the outward expression of exaggerated contractions of the 
intestine, especially of the colon; the pains of inflamma- 
tory origin are alleviated by the same means. In the first 
rank we would place Irygienic treatment. We must pro- 
tect the patients, especially if they are nervous or of the 
rheumatic temperament, from the action of cold; they 
ought to be warmly clad and wear woollen or flannel gar- 
ments, and especially should the}' wear flannel over the 
abdomen, for chilling of this region more than that of the 
general surface is a special cause of colic and diarrhoea. 

Opium and morphine are par excellence sedatives to the 
peristaltic movements of the intestine. Opium may be 
employed in the form of powder, extract, laudanum, black 
drop, or paregoric ; it enters into the composition of nu- 
merous formulae. One of the oldest of these and which is 
still in vogue is diascordium. This is really a combination 
of opium and of numerous astringent substances, the com- 
plex formula of which has been somewhat simplified. One 



DIAERHCEA. 199 

gramme of this electuary corresponds to six milligrammes 
of extract of opium. Diascordium is given to the amount 
of 4 to 8 grammes in half-gramme doses, either alone or 
combined with an equal quantity of subnitrate of bismuth. 
Bouchardat proposes the following formula as a substitute 
for diascordium : 



I£ Hydrochlorate of morphine, 


. 0. 03 gramme. 


Tannin, .... 


. 0.50 


Confection of rose, 


. 6.00 grammes 


Phosphate of calcium, . _ . 


. 3.00 


Tincture of balsam of tolu, . 


. 10.00 



M. Sig. One gramme of this mixture corresponds to 2 milli- 
grammes of morphine. 

Hydrochlorate of morphine may be used instead of 
opium, especially when it is impossible to give opium by 
the mouth, or when the pains are especially severe, as for 
example, when intestinal ulceration is present. 

The opiates are sometimes replaced by other sedative 
preparations, the good effects of which have been vaunted 
in diarrhoea. Indian hemp in doses of 10 to 30 drops of 
the tincture has been given for the relief of tropical diar- 
rhoea. Chlorodyne has also been employed for the same 
purpose. This is an English preparation, the formula for 
which is unknown. 1 

3. Treatment of Hijper secretion. — Two kinds of rem- 
edies will find mention under this rubric, viz., inert pow- 
ders and astringents. 

Certain powders appear to act as mechanical obstruants, 
at least we can explain their action only in this way, as 
their chemical effect is nil. It seems not improbable that 
these powders, collecting in considerable quantity in the 
large intestine, act as a sort of plug, which arrests or re- 
tards the evacuation of the contents of the bowel. It is 
said also that their presence in a thin layer over the sur- 
face of the intestine, especially an ulcerated surface, serves 
as a sort of protective against irritants. But whatever 

1 De Santi : De l'Entertie chronique Paludeenne ou Diarrhee de 
Cochinchine. 



200 DISEASES OF THE STOMACH AND INTESTINE. 

the explanation may be, the value of inert powders is be- 
yond question. Among these powders we shall consider 
subnitrate of bismuth, prepared chalk, oxide of zinc, and 
silicate of magnesia (talc). 

Subnitrate of bismuth has had a rather curious history. 
Orfila,» reasoning from experiments made upon animals, 
asserted that the drug was very poisonous, but he had 
ligated the oesophagus of the animals experimented upon, 
and it was from this that they had died. Nevertheless 
he had given the drug such a bad name that it required the 
repeated assurances of such observers as Bretoimeau, 
Trousseau, and Monneret to restore it to favor. Monneret 
maintains that it must be given in very large dose and says 
that we may give as much as "2 or '-> ounces without incon- 
venience. ' But the danger of this lies in the fact that the 
drug is often impure and contains lead or arsenic. Sev- 
eral writers have reported instances of poisoning by sub- 
nitrate of bismuth, some of them quite alarming, but the.y 
have occurred usually when the drug was used externally 
as an antiseptic dressing, being applied in large quantities 
to the open surfaces of wounds. Its internal administration 
is free from danger, provided rather moderate doses are 
not exceeded. Soulier says that a daily dose of 150 grains 
should not be exceeded. Nevertheless we must not forget 
that inert powders must be taken in sufficient quantity, as 
otherwise they are inefficacious. Nothnagel and Ross- 
bach, who formerly regarded bismuth as useless, now state 
that it has an excellent effect when given in doses of 45 to 
75 grains in diarrhoea depending upon ulcerative enteritis. 
Traube explains this favorable action by assuming that 
the bismuth covers the ulcerated surfaces and thus protects 
the nerve terminations against irritation by the faacal mat- 
ter. At the present time the subnitrate of bismuth is 
rather going out of employment, being replaced by other 
salts, especially by the salicylate; the use of the latter has 
been highly recommended by Vulpian, Desplats, and Du- 
jardin-Beaumetz because of its antiseptic properties, which 
'Soulier : "Traite de Therapeutique, " vol. ii., page 64. 



DIARRHCEA. 201 

it owes to the salicylic acid. It is given in doses of 45 to 
150 grains a day, often in combination with naphthol 
(Bouchard) . Borate of bismuth, proposed by Delpech, has 
not been found to be as useful, although boric acid is less 
irritating to the digestive tube and the kidneys than is 
salicylic acid. The borate is given in doses of from -J- to 
1 drachm a day. 

Prepared chalk is a remedy of real merit; it should be 
used in the rather large doses of from 2 to 5 teaspoonsfuls 
a day iu milk or sweetened water. It is often combined 
with other substances, such as subnitrate of bismuth, bi- 
carbonate of soda, etc. Prepared chalk being an alkali is 
particularly indicated in cases of gastric hyperacidity. 
Lime water is used more especially in the diarrhoeas of 
infancy, where it acts without doubt in virtue of its alka- 
line properties. 

Talc (silicate of magnesia) has been recommended by 
Debove ] in chronic diarrhoea and especially in the diar- 
rhoea of phthisis ; he gives it in the enormous doses of from 
3 to 18 ounces in milk, from 3 to 6 ounces being mixed in 
each quart of milk. We can go no further in the way of 
artificial obstruction of the intestine than this, but good 
results have been obtained from it, nevertheless. This 
salt has no appreciable taste and is taken readily by pa- 
tients. We have never given more than five ounces a day, 
but have never had any fault to find with our results. 

Oxide of zinc has been recommended in daily doses of 
45 or 50 grains with 10 grains of bicarbonate of soda taken 
in four doses. 

Tannin is the type of intestinal astringents, many sub- 
stances vaunted as efficacious in the treatment of diarrhoea 
acting only through the tannin which they contain. It is 
usually given in doses of 8 to 30 grains a day in pills of 
H to 3 grains each ; it may also be given in solution in a 
little whiskey and water. When it is desired to act upon 
ulcerations of the lower portion of the large intestine it 
may be given by enema in doses of 15 to 30 grains in a 
1 Societe des Hopitaux, June 8th, 1888. 



202 DISEASES OF THE STOMACH AND INTESTINE. 

pint of water, with or without the addition of 6 to 12 drops 
of laudanum. 

Rhatany is a very commonly employed astringent, which 
contains from 20 to 40 per cent of tannin. The extract is 
the most frequently used form. 

Catechu also depends for its efficacy upon the tannin 
which it contains. The syrup is a common form of ad- 
ministration and ma}' be given in doses of 1 to 3 ounces. 

Tannin, rhatany, and catechu, espeeiall}' the first two, 
are the most frequently prescribed tannic astringents, but 
there are a number of other substances which owe their 
constipating properties to tannin ; among these are straw- 
berry root, bistort (polygonum bistorta) tormentilla, wal- 
nut leaves, geum urbanum, etc. 

Acetate of lead may be useful in cases of intestinal ul- 
ceration; it is given in powder, pills, or solution in doses 
of J to 1 and even IV grains, up to as much as 7 grains a 
day. Coto and paracoto barks are no longer employed, 
having been replaced by cotoine and paracotoine, which are 
recommended in cases of subacute intestinal catarrh. Co- 
toine is given in doses J to 1-J grains in powder or mucilage, 
paracotoine in doses of J\ to 3 grains every two or three 
hours in powder mixed with sugar. 

4. Intestinal Antisepsis. — Antisepsis of the intestine 
can hardly be separated from that of the stomach, and as 
the indication for its employment is found in a number of 
different conditions, we have thought best to devote a spe- 
cial chapter to its consideration (See Chapter IX.). 

5. Restoration of the Lost Fluid to the Organism. — 
When the amount of water lost has been very great, seri- 
ous symptoms may result, due especially to heart failure 
and to the diminution, if not actual suppression, of the uri- 
nary secretion. This is seen in very marked degree in cases 
of cholera and of choleriform diarrhoea. The ingestion of 
water by the mouth does not suffice to make good the loss 
of fluid from the intestine, for this water is itself almost 
immediately rejected. For this reason it has been sug- 
gested to introduce water into the system either hypoder- 



DIARRH03A. 203 

mically or directly into the veins. Venous transfusion 
has been much vaunted in France by Hayem and his 
pupils, and was also largely employed during the last epi- 
demic in Hamburg and in Paris. 1 The temporary im- 
provement following this transfusion sometimes is most 
startling, and a certain number of actual cures may be 
credited to it. It is an operation that should be reserved 
for extreme cases, when collapse is marked and the radial 
pulse is imperceptible. 

But we ought not to wait until the patient is in such 
extreme danger before restoring the lost fluid to the organ- 
ism, and long before the radial pulse has disappeared we 
should practise subcutaneous injections of artificial serum 
(a hve-per-cent solution of chloride of sodium in distilled 
and sterilized water) . The injection should be made deeply 
under the skin by means of a long needle attached to a 
tube coming from a vessel raised above the point of injec- 
tion, or to a sterilized syringe. We may thus easily inject 
at one sitting 5 or 6 ounces of artificial serum . In certain 
cases of cholera I have injected in this way more than two 
pints of fluid. Six ounces can easily be passed under the 
skin in the course of twenty minutes, and the swelling 
caused by the presence of the fluid rapidly disappears. It 
is not only in cases of true cholera that this method can be 
employed, but it may also be used in any case in which 
there has been such a loss of water as to endanger the life 
of the patient, in choleriform diarrhoeas of any nature in 
children as well as in adults, in profuse chronic diarrhoea, 
malarial or otherwise, such as is frequently met with in 
hot countries and exceptionally in northern latitudes. 
Phosphate of soda, which, according to Luton, Crocq, and 
Peter, would seem to possess remarkable restorative pow- 
ers, may be added to the salt solution ordinarily employed. 

In closing this general study, we must remember that it 
is not advisable to suppress every diarrhoea of whatever 
sort; there are some that it is better to leave alone. Bou- 

1 Galliard : " Traitement du Cholera, " Gazette des Hopitaux, Feb., 
1893. 



204 DISEASES OF THE STOMACH AND INTESTINE. 

chard has seen certain cases of habitual diarrhoea, in a sense 
physiological, in which untoward symptoms followed the 
suppression of the discharge. These were doubtless cases 
in which the flux performed the office of removing toxic 
substances which, when retained and resorbed, became a 
source of danger. Uraemic diarrhoea should not be sup- 
pressed, for the discharge is salutary and removes the in- 
jurious products to which are due the ursemic symptoms. 
We should even endeavor to restore this diarrhoea when it 
has ceased, or at times to establish it. 

We must limit ourselves to the presentation of these 
general indications in the treatment of diarrhoea, for to 
enter upon a consideration of the therapy of the special 
clinical forms of the trouble would lead us too far, and it 
would require an entire volume to develop all the very 
complex elements entering into this question. The treat- 
ment of the diarrhoea of children would be more properly 
discussed in a work on the therapeutics of infantile dis- 
eases; the flux accompanying acute indigestion will re- 
ceive attention in a later chapter; the general principles 
of treatment of chronic diarrhoea will be discussed in the 
chapter on enteritis, and for rules concerning the manage- 
ment of the diarrhoea accompanying typhoid fever, ma- 
laria, and other acute febrile diseases the reader must con- 
sult special treatises on these subjects. We shall note in 
this place only nervous and morning diarrhoea. 

Nervous I)i<n-rh<>><<. — There are several types of this 
affection. An impressionable person, more or less neuro- 
tic, may be disturbed in mind by some annoyance or dis- 
appointment, and then has a sudden attack of diarrhoea. 
There seems to be a peculiar idiosyncrasy in these cases, 
and what would cause a flow of tears in others produces 
in them a diarrhoea. 

Tabetic diarrhoea is another of the nervous varieties. 
The urging to stool is imperative and is repeated ten to 
twenty times a day in a most monotonous way, although 
there is frequentlj r but a very small quantity of liquid 
matter to be passed. This form of the trouble is exceed- 



DIARRHOEA. 205 

ingly rebellious to treatment and may last for years ; in a 
patient of mine it existed for seventeen years. 

Chronic nervous diarrhoea has been well studied by 
Nothnagel. 1 The cases which he cites are really examples 
of true psychic diarrhoea. His patients were persons to 
whom the mere thought of going away from home where 
they would be at a distance from a water-closet was suffi- 
cient to create in them an urgent desire to stool, and this 
would be repeated several times a day. The disease was a 
diarrhceic form of agoraphobia. A persistent looseness of 
the bowels is not uncommon in neurasthenia. We have 
seen a patient, a pronounced neurasthenic, who could toler- 
ate absolutely no kind of meat, even a small quantity in 
whatever shape eaten causing a diarrhoea at once. The 
trouble began during a period of great anxiety in regard 
to financial matters. Trousseau has reported a case of 
chronic diarrhoea caused and kept up by the use of tea. 

Acute nervous diarrhoea usually passes away spontane- 
ously as soon as the exciting causes are removed, or if not, 
the enforcement of a few hygienic rules and a dose or two 
of opium will suffice for a cure. The form depending upon 
locomotor ataxia resists all treatment. The chronic psy- 
chic form calls for moral treatment, which will restore to 
the sufferer his lost confidence. The same applies also in 
great measure to the neurasthenic variety. We should 
observe the general principles of gastro-intestinal antisep- 
sis in regard to diet, and should be moderate in our em- 
ployment of the medicinal sedatives and antiseptics; such 
measures as hydrotherapy, massage, electricity, climato- 
therapy, and mental rest are specially indicated in these 
cases, and our endeavor should be to restore to the patient 
his confidence in himself. The moral treatment is here 
again of the greatest importance. 

Morning Diarrhoea. — Gueneau de Mussy and Ollive 2 
have described a peculiar clinical type, of which we have 
seen some examples, characterized by the occurrence of 

1 " IJeber nervose Diarrhoe. " 

2 A. Chaunet, These de Paris, 1888. 



206 DISEASES OF THE STOMACH AND INTESTINE. 

several loose passages in the morning but without any re- 
turn during the day. The condition persists indefinitely. 
A similar phenomenon is observed rather frequently in 
cases of hyperchlorhydria, but the treatment here is that 
of the causal condition. The treatment of morning diar- 
rhoea is mainly dietetic. We must reduce the amount of 
fluids ingested, forbidding red wine entirely, and prescribe 
chiefly roast or broiled meat, eggs, and, in moderate 
amount, milk products, purees of dried vegetables, and 
stewed fruit. It is often specially useful to diminish the 
quantity of food taken at the evening meal. 

If the stools are fetid we must resort to gastro-intestinal 
antisepsis; giving chloroform water somewhat diluted, 
Hayem's lactic-acid lemonade, naphthol, and salicylate of 
bismuth, or benzoi laphthol. The last-named agent is the 
one that we should prefer to give in these cases. 



CHAPTER IX. 
GASTRO-INTESTINAL ANTISEPSIS. 

The possibility of auto-intoxication originating in the 
intestinal canal and the utility of antisepsis of the diges- 
tive tract are now well recognized, and it would hardly be 
necessary to refer to the theory of auto-intoxication at all 
were it not that we desire to recall the principles upon 
which treatment is based and to point out some widespread 
errors on the subject. In the management of this condi- 
tion we must make a very careful selection among the nu- 
merous drugs and formulae which have been recommended 
and employed. In our study of the subject we shall begin 
with the food before its introduction into the stomach and 
follow it in its course through the digestive tube. 

Fermentation of Food Outside of the Body. — Alimen- 
tary substances, especially the nitrogenous, while undergo- 
ing putrefaction give origin to a number of toxic products 
which are analogous in their action to the most powerful 
of the vegetable alkaloids ; these are the ptomaines which 
have been studied of late by many observers, and which, 
when ingested with the foods in which they have been 
developed, give rise to serious accidents that have been 
grouped together under the common term botulism. Other 
substances may be ingested at the same time which, while 
not yet poisonous, become so in the process of decomposi- 
tion in the intestine and thus occasion a continuous for- 
mation of toxines ; this explains the occurrence of certain 
diseases of slow evolution resembling typhoid fever, which 
are, however, of the same nature as the more acute phe- 
nomena. Decomposing food, therefore, may give rise to 
poisoning or to infection. We shall see later how to treat 

207 



208 DISEASES OF THE STOMACH AND INTESTINE. 

this condition when already established, but first let us 
study the means of its prevention. 

We may prevent the further production of these symp- 
toms entirely in many cases by insisting upon a complete 
abstinence from food, but this must, from its very nature, 
be a temporary expedient only. There are two conditions 
upon which the success of this dietetic treatment depends : 
(a) The avoidance of food already undergoing putrid de- 
composition, and (b) the choice of those articles which not 
only contain a minimum of toxines and of the germs of 
decomposition, but which also afford the least favorable 
field for the occurrence of this process. 

(a) Whenever there exists a tendency to auto- intoxica- 
tion, either because intestinal fermentation is excessive or 
because the poisons are not eliminated through the kidneys 
or destroyed in their passage through the liver, we must 
take special care to prevent the introduction of food pro- 
ducts already undergoing decomposition. This indication 
is present not only in cases of gastro-intestinal disease, but 
also whenever, in consequence of organic or functional 
trouble of the liver or kidneys, there is a 1 (sorption or reten- 
tion in the economy of an abnormal quantity of toxines. 
In such cases we should forbid all high or richly seasoned 
meat, strong cheese, etc. 

(b) Sufferers from auto-intoxication should be allowed 
to take only perfectly sound articles of food and those 
which are least liable to become the seat of putrid fermen- 
tation within the intestine. This process is especially 
favored by two conditions, viz., an excessive quantity of 
food, particularly of nitrogenous food, and the presence of 
a considerable amount of indigestible residue. 

A milk diet fulfils these two indications admirably. It 
introduces into the digestive tract but a very small pro- 
portion of toxines or of micro-organisms, and it leaves a 
minimum quantity of waste material; it is also easily 
elaborated and easily absorbed, and furthermore increases 
the urinary secretion. This is an explanation of its good 
effects in diarrhoea, enteritis, etc. It is justly entitled to 



CASTRO-INTESTINAL ANTISEPSIS. 209 

the first rank among foods suitable for those cases in 
which auto-intoxication plays an important part in the 
production of the morbid symptoms. Nevertheless milk 
may itself furnish a vehicle for the introduction of patho- 
genic microbes, of the coli bacillus or of the bacillus of 
lactic acid fermentation, which latter, as Wurtz and 
Leudet have shown, may occasion the production of 
toxines by its action upon albuminoid substances. For 
this reason great care should be taken to see that the milk 
is fresh, comes from healthy animals, and is as far re- 
moved as possible from all causes of fermentation. 

Sterilized milk represents the ideal aliment, and it has 
been found to give excellent results in the treatment of 
diarrhoea, especial in children. All patients cannot be 
subjected to an absolute milk diet, for various reasons, but 
in any case it constitutes a valuable addition to a mixed 
regimen. 

By means of the vegetable diet described in a preceding 
chapter we are enabled to limit greatly the introduction of 
nitrogenous substances and to give them in the least in- 
jurious form. This dietary consists essentially in milk 
and. dairy products, eggs, and vegetable purees ; the food 
is in a state of minute subdivision and free from all excess 
of indigestible matter. The fine division of food is inimi- 
cal to the occurrence of putrid decomposition, as it brings 
every particle into close contact with the digestive fluids. 
It is important also to reduce to a minimum the amount 
of indigestible waste material, whether of animal or veg- 
etable nature. For this reason all fat, vessels, tendons, 
and aponeuroses, and whatever is not actually muscular 
tissue, should be removed from the meat ; it is chiefly be- 
cause of this careful preparation that raw meat pulp is 
of such service in diarrhoea. Cooked meat should be well 
cooked, for that in itself is a good antiseptic measure. 
The same indication is met in the case of vegetable articles 
of diet by serving them in the form of purees. For a 
further exposition of this important subject of diet the 
reader is referred 'to Part II. 
14 



210 DISEASES OF THE BTOMACB .VXD INTESTINE. 

Gastric Antisepsis. — When the food has reached the 
stomach it is submitted to the action of the saliva, which 
acts upon the starchy matters, and to that of the gastric 
juice, which acts upon the nitrogenous portions, whether 
of animal or of vegetable origin. The hydrochloric acid 
of the gastric juice is a true antiseptic agent, as has been 
shown bj- numerous experiments. This antisepsis, how- 
ever, is never complete and many microbes of fermenta- 
tion are passed along with the food into the intestine. 
There are two reasons why natural antisepsis of the stom- 
ach is never complete: in the first place hydrochloric acid 
is not present in sufficiently large amount, and secondly, 
the period during which the food remains in the stomach 
is too short for this process to bo perfected. Straus and 
Wurtz found that the gastric juice of the dog, although 
very rich in hydrochloric acid, required a week for com- 
plete sterilization. Even in cases of hypersecretion of 
hydrochloric acid we often detect an organic hyperacidity 
resulting from secondary fermentations which the acid of 
the gastric juice, although in excess, was not able to pre- 
vent. We may conclude, therefore, that although there is 
a true antiseptic power in the gastric juice we must not 
exaggerate its importance, as has been done b} T Bouchard 
in his conception of the pathogenic role of dilatation of 
the stomach. 

The interesting experiments of Wasbutzki 1 have shown 
that the sulpho-acids are increased in cases of hyperchlor- 
hydria. But the sulpho-acids in the urine appear to serve 
as a measure of the intensity of intestinal fermentation 
and of putrid auto-intoxication. It is certain that sec- 
ondary fermentation, manifested by organic hyperacidity, 
takes place in the stomach when there is stagnation of 
the food in this organ. This fermentation is locally in- 
jurious in consequence of its irritant action upon the gas- 
tric mucous membrane and it may well be believed that 
it may also give rise to toxic products, although experi- 

l Archiv fur experiment. Pathol, und Pharmakologie, vol. xxvi., 
p!33. 



GASTRO-INTESTINAL ANTISEPSIS. 211 

mentally the toxic properties of the contents of the stomach 
have been demonstrated only in cases of hypersecretion of 
hydrochloric acid with stagnation complicated by tetany. 
This toxicity is due, according to Bouveret and Devic, ! to 
the presence of imperfectly elaborated peptone. The 
occurrence of excessive fermentation and of organic 
acidity can hardly be imagined unless there is stagnation 
of the gastric contents. Although this stasis may be 
much less common than has been supposed, it never- 
theless exists in certain cases with or without actual 
lesion of the stomach, and we are therefore justified in 
devoting a special paragraph to the study of gastric anti- 
sepsis. 

This antisepsis has been attempted by chemical and 
mechanical means. We can hardly separate the study of 
chemical antisepsis of the stomach from that of the intes- 
tine, and we may say at once that mechanical antisepsis 
of the stomach by means of lavage seems to us far better 
than any chemical methods. 

Mechanical antisepsis of the stomach is effected by 
means of artificial evacuation of its contents through the 
cesophagus, and this evacuation may be accomplished 
naturally by vomiting or artificially by lavage. Gastric 
indigestion naturally terminates by vomiting, just as 
diarrhoea often puts an end to intestinal indigestion. We 
have imitated nature in this respect, so that an emetic is 
the time-honored remedy for acute indigestion. 

Lavage of the stomach is less distressing than vomit- 
ing, is more easily repeated from time to time, and is also 
an excellent means of bringing about the removal of the 
peccant material. It may be made with pure water or 
boiled water if preferred, but the use of various antiseptic 
solutions has been recommended, not only as a means of 
obtaining more complete disinfection, but also with the 
object of leaving in the digestive tube a more or less con- 
siderable amount of a fluid which may moderate the pro- 
cess of fermentation. For this purpose we may employ 
1 Revue de Medecine, 1887. 



212 DISEASES OF THE STOMACH AND INTESTINE. 

solutions of boric acid (3 per cent), of salicylic acid (2 or 
3 parts per 1,000), of borax (2 per cent), of creolin (0.5 per 
cent), of thymol (1 : 2,000), and of many other substances, 
such as resorcii), permanganate of potash, chlorate of 
potash, chlorate of soda, hyposulphite of soda, chloride of 
sodium, etc. We may also use solutions of hydrochloric 
acid (1 or 2 parts per 1,000), and of lactic acid (5 parts per 
1,000). It is not improbable that Vichy water, which has 
recently been employed to some extent in washing out the 
stomach, increases the natural antiseptic properties of the 
gastric juice by provoking a greater secretion of hydro- 
chloric acid. 

Intestinal Antisepsis. — We may here also practise 
mechanical antisepsis or resort to the administration of 
medicinal antiseptics by the mouth. Under mechanical 
antisepsis we include purgatives and lavage of the intes- 
tine by the rectum. 

Purgatives have long been used in the treatment of 
gastro-intestinal indigestion, when the intestinal symp* 
toms predominated, and of certain forms of diarrhoea. It 
is entirely rational to endeavor to obtain a cleansing of 
the intestinal tract by means of active purgation. Saline 
purgatives and aperient mineral waters act well in these 
conditions. It is well known that constipation usually 
follows the laxative effect obtained by their use and this 
explains their beneficial effect in diarrhoea. Calomel is 
at once a purgative and a mercurial salt. It gives origin 
in the intestinal tube to a small quantity of the bichloride 
and to a larger amount of the sulphide of mercury, both 
of which are antiseptics. In consequence of this calomel 
has naturally been regarded as the best purgative when it 
was desired to overcome intestinal fermentation. We 
may add that its easy administration to children and the 
good effects which it produces in the diarrhoeas of early 
life has still further won .the favor of physicians. Un- 
fortunately there is no proof that calomel administered by 
the mouth exerts any really valuable antiseptic effect in 
the intestine, for experiments made to determine this 



GASTRO-INTESTIXAL ANTISEPSIS. 213 

point have been negative in their results. 1 But in spite 
of this it remains the remedy of choice in children because 
of its absence of taste and ease of administration. 

Lavage of the intestine is possible only as regards the 
lower bowel, although it has been pretended, without 
sufficient proof, however, that liquids may be made to 
pass be} T ond the ileo-caecal valve and enter the lower part 
of the small intestine. Enteroclysis may be practised 
with an ordinary stomach tube or by means of a special 
apparatus devised for the purpose. If the stomach tube 
is used it should be introduced as far as possible above 
the sphincters and then, by means of a funnel connected 
by a long rubber tube with the tube in the rectum, the 
water is made to enter the intestine. This simple appa- 
ratus may be replaced by one specially constructed for the 
purpose (enter oclyseur h entonnoir), but the only advan- 
tage of this is that the reservoir may be raised or lowered 
at will so as to cause the fluid to flow back and forth into 
and out of the bowel. This manoeuvre has been recom- 
mended as a good means of breaking up hard masses 
which have accumulated in the colon. While lavage is 
being performed the patient should be in a recumbent 
posture; two or three quarts of water may be used. 

Ascending douches, such as are given at certain mineral 
springs, are only a variety of enteroclysis. The patient 
sits upon a special machine, the tube is introduced into 
the rectum, and then a stopcock is gradually opened, let- 
ting in the water coming from an elevated reservoir. 
After a while the excess of fluid escapes between the tube 
and the sphincter, so that a continuous irrigation of the 
large intestine is effected. It would, however, be better 
to practise this lavage with the patient in the recumbent 
posture, as then there would be a greater likelihood of the 
water passing well up into the intestine and so washing 
it out more thoroughly. 

Enteroclysis may be made with antiseptic solutions or 

1 Biernacki : Deutsches Archiv fur klinische Medicin, p. 87, 
1891. Steiff : Zeitschrift fiir klinische Medicin, xii., p 310. 



214 DISEASES OF THE STOMACH AND INTESTINE. 

with naphthol water (3 or 4 grains to the quart), saturated 
solution of sulphide of carbon, or weak solutions of per- 
manganate of potash or of nitrate of silver (1-J to 7 grains 
to the quart). Cantani has recommended enteroclysis 
with a tannin solution in the treatment of cholera. In 
cases of muco-membranous enteritis Dujardin-Beaumetz 
advises iodine water (2^ drachms of the tincture to a 
quart of water) and naphthol water. Bouchard says that 
a saturated solution of boric acid is very irritating to the 
mucous membrane of the large intestine, and he warns 
against its too frequent use. 

When the lesion is situated in the lower part of the 
large intestine and it is not necessary to carry the remedy 
very far, we may use smaller enemata and more concen- 
trated solutions; Ave shall return to this when we come to 
the chapter devoted to the treatment of dysentery. 

Medicinal antisepsis lias been the subject of much ex- 
perimentation and there is hardly any antiseptic substance 
which has not been tried in the disinfection of the intes- 
tinal tube. Before enumerating these substances and 
dwelling upon those which deserve study, we may ask 
ourselves whether intestinal auto-intoxication really exists 
and if we are able to combat it effectually. 

The reality of intestinal auto-intoxication is shown 
by: (1) the toxicity of the fa?ces; ' (:>) the presence in the 
urine of substances which owe their origin to putrid fer- 
mentation taking place in the intestine; (3) the appear- 
ance of grave symptoms when the progress of the faecal 
matters is arrested (strangulated hernia, intestinal ob- 

'Gilbert, in an interesting communication marie to the Biologi- 
ca I Society of Paris (February 25th, 1893), has shown that the coli 

bacillus which is present in such numbers in the intestine of man 
elaboratesa powerful toxine which, when injected into the veins of 
rabbits, causes convulsions, coma, and tetanic contractures. It is 
then very probable that the coli bacillus elaborates in the intestine a 
quantity of toxine which may be capable of exciting more or less 
grave symptoms of auto-intoxication. We know that in certain diar- 
rhoeas, especially those of early life, the contents of the intestine may 
be nothing more than a pure culture of the coli bacillus (Lesage) . 



CASTKO-IXTESTINAL ANTISEPSIS. 215 

struction) ; (4) the diminution of the toxicity of the urine 
in proportion as that of the intestinal contents decreases. 

It is therefore proper to seek to restrain intestinal fer- 
mentation when it tends to assume an exaggerated impor- 
tance, as happens in a number of cases which were formerly 
grouped under the common name of acute or chronic 
enteritis, in many cases of constipation, of organic lesions 
of the intestine of chronic colitis, and when disease of the 
liver or of the kidney interferes with the destruction of 
these toxines or with their elimination in the urine. Nu- 
merous attempts have been made to effect gastro-intestinal 
antisepsis. Bouchard's investigations in this regard were 
epoch-making. At the Copenhagen Congress he laid down 
certain general rules concerning gastro-intestinal anti- 
sepsis. A good antiseptic he said should possess the fol- 
lowing properties : it should be insoluble and should be 
given in the form of an impalpable powder and in fraction- 
al doses. It should be insoluble, or at least very slightly 
soluble, so that it may not be absorbed and produce symp- 
toms of acute poisoning. It should be in the form of an 
impalpable powder so as to penetrate into all the folds of 
the mucous membrane and thus become intimately mixed 
with the fsecal matters. It should be given in fractional 
doses so as to be spread equally as far as possible throughout 
the entire length of the intestinal tube. There are, indeed, 
certain soluble antiseptics which may be given in liquid 
form and which possess a certain value; we shall mention 
some of these below. But this does not detract from the 
value of the general theory of antiseptics as laid down by 
Bouchard. 

This author tried a considerable number of antiseptics 
before deciding upon beta-naphthol and salicylate of bis- 
muth as the best. He obtained no good results with the sul- 
phites, the hyposulphites, carbolic acid, creosote, and boric 
acid. Salicylate of bismuth had already been recom- 
mended by Vulpian, naphthalin by Rossbach, and the black 
sulphide of mercury by Serres and Becquerel. Others 
have recommended hydrochloric acid, lactic acid, salol, 



21G DISEASES OF THE STOMACH AND INTESTINE. 

thymol, betol, eucalyptol, iodoform, dermatol, resorcin, 
benzonaphthol, vegetable charcoal, etc. 

We must make a choice among all these substances, and 
shall begin by eliminating two which are dangerous on 
account of their poisonous properties, viz., black sulphide 
of mercury, which may be absorbed in dangerous amounts, 
and naphthalin, which causes symptoms of vesical and 
urethral irritation. A certain number of substances owe 
their antiseptic property to the presence of free or combined 
salicylic acid; these are salicylate of bismuth and of mag- 
nesia, salol, betol, and eucalyptol. They all have the dis- 
advantage that salicylic acid is irritating to the mucous 
membrane and may occasion serious symptoms to patients 
whose kidneys do not act well. 

Salicylate of bismuth is decomposed into salicylic acid 
and oxide of bismuth. It possesses some real value and 
is often employed alone or in combination with other anti- 
septic and astringent substances. It is given in the amount 
of 30 to 150 grains a day in divided doses of 7 to 15 grains 
each. 

Salicylate of magnesia is often combined with naphthol 
when constipation exists, just as salicylate of bismuth is 
combined with it when there is diarrhoea. It is given in 
doses of 30 to 75 grains. It has been recommended by 
Huchard in the treatment of typhoid fever. 

Salol is formed by the combination of carbolic and sali- 
cylic acids, and breaks up into these substances in the in- 
testine under the influence of the pancreatic juice; it is 
said to pass into the intestine unaffected by the gastric 
juice, although this is denied by Reale and Grande. It is 
often employed as an intestinal disinfectant, and has given 
good results in cases of infectious diarrhoea. 

Betol is a salicylate of naphthol, and is wholly insoluble 
in the stomach. It is decomposed in the intestine into 
naphthol and salicylic acid. Hay em sa3 T s that it tempo- 
rarily causes a lowering in the amount of free and com- 
bined hydrochloric acid and retards gastric digestion, and 
as it also gives rise to salicylic acid in the intestine it is 



GASTROINTESTINAL ANTISEPSIS. 217 

less desirable than benzo-naphthol, of which we shall speak 
later. 

Eucalyptol is simply a mixture of carbolic acid and oil 
of eucalyptus, each one part, and salicylic acid six parts. 
The large proportion of salicylic acid which it contains 
and its burning taste render it a rather poor antiseptic of 
the intestinal tract. It is given in doses of from 60 to 90 
grains a day. 

Vegetable charcoal is a good antiseptic which Bouchard 
was for some time in the habit of using in the treatment 
of typhoid fever. He obtained by means of it a complete 
deodorization of the faeces, which is a very positive proof 
of its an ti -putrefactive action. He gave it in doses of 3 
ounces a day with the addition of 15 grains of iodoform in 
glycerin. But the author himself confesses that it re- 
quired real courage to swallow the mixture, and he has on 
this account given it up notwithstanding its valuable an- 
tiseptic properties. Beta-naphthol is the antiseptic pre- 
ferred by Bouchard, and in consequence of his strong en- 
comiums it quickly made its way into practice and took 
the first rank among remedies of its class ; it is now, how- 
ever, being in a measure displaced by benzonaphthol. 
The following is the formula of Bouchard : 

I£ Beta-naphthol, 3 iv. 

Salicylate of bismuth, 3 ij. 

M. Divide into 30 powders. Sig. Take from 3 to 12 powders 
in the twenty-four hours. 

Taken in this way the naphthol deodorizes very effectually 
the faecal matters. It acts upon both the intestine and the 
stomach, but Hay em does not regard this as an advantage. 
He says that it is an extreme irritant to the stomach and 
in consequence of this it causes at first an exaggeration of 
the secretion of hydrochloric acid and later leads to ex- 
haustion of the mucous membrane and a reduced secretion 
of this acid. Naphthol would in that case be absolutely 
contra-indicated when there is hyperchlorhydria, and 
should be given in other cases very cautiously and for not 
too long a period. As we have said above, naphthol is 



218 DISEASES OF THE STOMACH AND INTESTINE. 

often combined with salicylate of bismuth ; it may also be 
given associated with bicarbonate of soda, prepared chalk, 
magnesia, salicylate of magnesia, rhubarb, etc. Alpha- 
naphthol, which is even less toxic, is said to possess more 
marked antiseptic properties. 

Resorcin is recommended as a gastro-intestinal antisep- 
tic by some; it is given in solution in doses of 30 to 75 
grains a day. The following formula for a gastric anti- 
septic is given by Menche : 

K Pure hydrochloric acid, 

Resorcin a&gr. xxx. 

Syrup of orange-peel, ... : v. 

Water Z vi - 

M. Sig. A tablespoonful every two or four hours. 

Benzonaphthol. prepared for the first time by Maikopar 
in 1809, was studied anew by Yvon and Berlioz in 1891. 1 
Being almost insoluble in water, it passes through the 
stomach without being modified and splits up in the intes- 
tine into naphthol and benzoic acid ; the antiseptic action of 
the latter aids that of the naphthol and as it is much less 
irritating than salicylic acid, it follows that benzonaphthol 
is preferable to betol. The benzoic acid is eliminated in 
great part by the urine as hippuric acid. Gilbert" lias 
found that benzonaphthol has no action whatever upon the 
gastric secretion and is therefore markedly superior to 
naphthol in this respect. Given in doses of 60 to 75 grains 
a day in powders of 8 grains each, it is in no sense injuri- 
ous, does not disturb digestion, and exerts upon the con- 
tents of the intestine an antiseptic action equal to that 
obtained from 40 grains of naphthol. It wpuld seem to be 
the intestinal antiseptic par excellence; the dose of 75 
grains may even be exceeded without danger. Le Gendre 3 
has also experimented with a number of antiseptics and 
gives the preference to benzonaphthol, which he has found 
useful in very many diseases of the intestines. We have 

1 Societe de Therapeutique, November 11th, 1891. 
-Societe Medicate des Hopitaux, May 6th, 1892. 
3 Ibid.. May 13th, 1892. 



GASTRO-INTESTINAL ANTISEPSIS. 219 

also employed it in Asiatic cholera, in cholera nostras, in 
summer diarrhoea, dysentery, and in acute attacks of muco- 
membranous enteritis, and have found it to produce excel- 
lent results. When, therefore, we desire specially to ob- 
tain antisepsis of the intestinal tract we must give the 
preference to benzonaphthol. 

When antisepsis of the stomach alone is aimed at we 
must resort in the first place to lavage and secondly to one 
of the following medicinal antiseptics: hydrochloric or lac- 
tic acid, chloroform water, sulpho-carbonated water, resor- 
cin, or boric acid. As regards hydrochloric acid we would 
refer the reader to what has been said apropos of the acid 
treatment of dyspepsia and of dilatation of the stomach. 

Lactic acid is considered by Hayem to be an excellent 
gastro-intestinal antiseptic. After having, with Lesage, 
observed its good effects in the green diarrhoea of children, 
he was led to use it with success in a number of other 
forms of diarrhoea. 1 He gives it in the form of a lemon- 
ade composed of ■£ ounce of lactic acid to 7 ounces of 
simple syrup and 25 ounces of water. This mixture, which 
is easy to take, was much prescribed during the last epi- 
demic of cholera. Most of those who have used it have 
been satisfied with its action without, however, attaching 
undue importance to it as a remedy. It is given in doses 
of half a glass. 

In cases of dilatation of the stomach with excessive fer- 
mentation, we are in the habit of giving, from time to time, 
a saturated solution of boric acid in doses of 7 to 10 ounces ; 
this amount is given in several portions while digestion is 
going on, with apparently good effect. 

It may be asked whether gastro-intestinal antisepsis is 
justified by the results obtained, but independently of the 
benefits which the patients express themselves as feeling, 
a number of other facts bear witness to the realit}^ of anti- 
sepsis of the digestive tract. On the one hand the bad 
odor of the intestinal discharges is diminished or abolished, 

1 Academie de Medecine, October 25th, 1887 ; Societe Medicale 
des Hopitaux, June 27th, 1890. 



220 DISEASES OF THE STOMACH AND INTESTINE. 

and on the other the toxic power of the urine is lessened and 
the amount of the products of putrefaction which it con- 
tains, especially of the sulpho-acids and of cyanuric acid, 
is reduced. Intestinal antisepsis is, therefore, a palpable 
fact capable of actual demonstration. Nevertheless it has 
been doubted. Stern ' says that the sulpho-acids are an 
indication of putrefaction only and that they have no 
reference to infectious or toxic processes going on in the 
intestine. 

The faeces are never completely sterilized by internal 
antisepsis, and they always offer a medium for microbic 
cultures. When animals have been fed with a pure cul- 
ture of the bacillus prodigiosus, no matter how powerful 
the antiseptics administered, nor how large the doses, the 
microbes are always found in the faeces. But it would not 
be desirable to sterilize completely the intestinal tract, for 
then the digestive process would necessarily be suspended. 
The object is merely to restrict auto-intoxication as far as 
possible. There is no doubt that this result may be ob- 
tained in great measure by the use of purgatives, lavage 
of the stomach and of the large intestine, by an appropri- 
ate diet, and by the administration of suitable antiseptics, 
^eitschrift fur kliiiische Medicin, vol. xii. 



CHAPTER X. 
DYSPEPSIA.— ACUTE INDIGESTION. 

These terms express two Yery different things which 
yet have so many semeiological and pathogenic points in 
common that the confusion in their nomenclature appears 
to be justified. Dyspepsia and acute gastric or rather 
gastro-intestinal indigestion are symptomatic complexes 
which correspond often to phenomena of auto-intoxication 
of digestive origin. 

It would perhaps be well to distinguish from the rest 
nervous dyspepsia, which is to the stomach what nervous 
diarrhoea is to the intestine. In consequence of some men- 
tal or physical shock, received during or soon after a meal, 
the individual is seized with malaise, pallor, cold sweats, 
nausea, and giddiness, and soon vomiting occurs and puts 
an end to the scene. The whole trouble may subside in 
this way or symptoms of acute indigestion may still remain. 

In other cases the symptoms do not appear at once, but 
after the lapse of a certain time. After a more or less co- 
pious repast the person retires and falls asleep without diffi- 
culty. At the end of several hours he awakes with a feel- 
ing of extreme malaise, of weight on the stomach, nausea, 
heaviness of the head, and oppression. The face is often 
pale, sometimes covered with sweat, the pulse is small and 
rapid. These symptoms are occasionally so severe as 
greatly to alarm the patient and those about him. They 
may terminate with copious vomiting or sometimes with 
a sharp attack of diarrhoea, and the patient recovers after 
the evacuation of the peccant material ; or here again an 
acute gastric indigestion may succeed to this stormy be- 
ginning. 

Sometimes gastric indigestion may begin in a suba- 

221 



222 DISEASES OF THE STOMACH AND INTESTIXE. 

cute form. It is characterized by general malaise, lassi- 
tude, a feeling of heaviness in the head or actual head- 
ache, anorexia and even a repugnance for food, and fre- 
quently a heavily coated tongue. To these initial symptoms 
may succeed phenomena more directly referable to the in- 
testine, such as colic and diarrhoea. 

Sometimes there is an elevation of temperature, acute 
febrile indigestion, and the fever may be so marked as to 
lead to a suspicion of typhoid fever, the differential diag- 
nosis at this stage being at times a matter of considerable 
difficulty or even impossible until the course of the malady 
has been watched for a certain period. 

In some cases the intestinal symptoms are more marked 
than the gastric. These consist in distention of the abdo- 
men with constipation or in diarrhoea, quite frequently 
fetid diarrhoea. 

It is really to food-poisoning of intestinal origin that 
these symptoms are duo, and in other different cases the 
semeiological complex is to be explained by an analogous 
pathological process, viz., auto-intoxication. However, 
the causes and nature of this auto-intoxication are very 
different in differenl cases. Sometimes the person has 
overeaten and the stomach and i ntes tine are unable to elab- 
orate the great massof food which then undergoes fermen- 
tation. Again it is not the quantity but the quality that 
is at fault; something already undergoing dee«»mposition 
has been eaten and has carried with it poisons ready formed 
and micro-organisms of fermentation. 

Simple poisoning will give rise to temporary symptoms; 
infection to a prolonged morbid condition, sometimes ac- 
companied by fever. Both the intoxications and the in- 
fections which may cause acute indigestion are extremely 
varied, and various also are the symptoms to which they 
may give rise. All persons are not equally affected by the 
same cause, for there are many very strange and inexplica- 
ble individual predispositions. Some persons, for example, 
cannot eat duck without suffering almost immediately 
from colic and diarrhoea, while others cannot partake of 



DYSPEPSIA. — ACUTE INDIGESTION. 2:23 

<?old fish without paying the penalty in the shape of an 
attack of acute indigestion. The same toxines do not pro- 
duce the same effects in everybody, and it is very possible 
that different individuals elaborate different toxines from 
the same kind of food. 

Any disturbance of the gastro -intestinal movements pre- 
disposes to acute indigestion. In certain cases of atonic 
dyspepsia with a tendency to gastric stasis we see repeated 
attacks of acute indigestion or an almost permanent morbid 
condition which is very analogous to it; it is a chronic 
gastro- intestinal indigestion. It is not improbable that, 
as Bouchard asserts, the absence or reduced amount of 
hydrochloric acid plays an important role in the production 
of these symptoms ; the natural antisepsis of the digestive 
tract is wanting. In others it is the atony of the intestine 
that is at fault; there is a retention of faecal matters in 
the bowel and consequent auto-intoxication. From this 
result the symptoms, with or without fever, seen especially 
in cases of chronic muco-membranous colitis. 

In all cases of gastro-intestinal indigestion, whatever the 
symptoms may be, there are certain general indications of 
treatment. We must: (1) remove as rapidly as possible 
the injurious matters from the stomach or intestine ; (2) 
reduce to a minimum the food poisoning; (3) secure an- 
tisepsis of the digestive tube; (4) aid the elimination of 
the toxines already absorbed. We shall see that the clas- 
sical treatment of this condition meets very well the indi- 
cations which modern research has enabled us to express 
in more scientific formulae. 

1. Removal of the injurious matter from the digestive 
canal is often accomplished naturally by vomiting and 
diarrhoea, and the physician has only in this respect had 
to copy nature; he has produced vomiting when the stom- 
ach was or seemed to be chiefly at fault, and purgation 
when the trouble was located in the intestine. This is the 
traditional treatment of acute indigestion, and there is no 
reason for abandoning it now ; for every one knows that it 
usually gives results as speedy as they are good. Nausea, 



224 DISEASES OF THE STOMACH AND INTESTINE. 

distaste for food, and a coated tongue, without diarrhoea, 
call for the administration of an emetic ; constipation, es- 
pecially when there are intercurrent attacks of diarrhoea, 
abdominal distention, and fetid diarrhoea are indications 
for the administration of a purgative. In these cases pur- 
gative salines, such as sulphate of soda or of magnesia and 
the citrate of magnesia, are to be employed. We may also 
use the purgative mineral waters, of which we have a large 
choice. 

Acute indigestion may recur with abnormal frequency 
in certain patients, especially those who have a tendency 
to atony of the stomach with stagnation of its contents and 
those who suffer from habitual constipation. It is evident 
that here we have to treat the atony of the stomach or in- 
testine. We must also frequently take into consideration 
the neurotic condition underlying the trouble. 

2. The prevention of food poisoning is best obtained by 
a milk diet. When we cannot keep the patient on milk 
alone we must reduce the amount of food to a minimum 
and give only those articles which are most easy of diges- 
tion; boiled eggs are very useful here. For a further con- 
sideration of the diet suitable to these cases the reader is 
referred to Part II. 

:>. Antisepsis of the Digestive Tube.— This is accom- 
plished mechanically by emetics and purgatives, to which 
we may add lavage of the stomach in cases of atonic dila- 
tation. When there is marked tendency to vomiting we 
may give chloroform water. In cases of diminished secre- 
tion of hydrochloric acid, with organic fermentation in 
the intestine, accompanied by acid eructations and an acid 
or fetid breath, we may give hydrochloric or lactic acid 
lemonade. The same result would doubtless be obtained 
by the administration of small doses of an alkali before 
meals. It is a common practice in these conditions to give 
alkaline mineral waters with milk, the good results of 
which are doubtless due to the fact that the secretion of 
hydrochloric acid is thereby momentarily increased. The 
existence of diarrhoea, especially of fetid diarrhoea, is an 



DYSPEPSIA. — ACUTE INDIGESTION. 225 

indication for the administration of medicinal antiseptics, 
such as salol, naphthol, salicylate of bismuth, and prefer- 
ably, for the reasons given above, benzonaphthol. 

Elimination of the Toxines. — It is not sufficient to pre- 
vent the production of new toxines by means of diet and 
of gastro-intestinal antisepsis, and to get rid of those re- 
maining in the intestinal tract, but we must also do what 
we can to favor the elimination by the kidneys of those 
which have been absorbed. To do this we must provoke 
diuresis by means of milk and of mineral waters ; it is not 
necessary to resort to other diuretics. 

Sometimes the vomiting by which an attack of acute 
indigestion has been terminated becomes excessive and 
continues longer than is necessary. This must be combated 
by ice, iced drinks, Riviere's potion, chloroform water, and 
cocaine. 

An attack of acute indigestion is sometimes followed by 
more or less prolonged anorexia. For this we may resort 
to bitter tinctures, especially gentian and calumba, or nux 
vomica with the addition, of a small amount of tincture of 
ipecac. It is far better to give these bitters after a meal, 
while digestion is going on, rather than, as is commonly 
done, before eating. 

The exclusive use of hot drinks at meals is often very 
useful in those who have a tendency to nervo-motor atony 
of the stomach. 
15 



CHAPTER XL 
GASTRIC AND INTESTINAL HEMORRHAGE. 

The treatment of profuse hemorrhage is very nearly the 
same, whether it occurs from the stomach or from the in- 
testine. The first indication is to secure absolute rest for 
the patient in a recumbent posture. An ice-bag may be 
applied to the epigastric region if the bleeding comes from 
the stomach. Only liquid food, preferably cold milk, 
should be given. Little bits of ice should be swallowed 
whole and not be allowed to melt in the mouth. 

We should endeavor as soon as possible to obtain im- 
mobilization of the stomach and intestine. Opiates may 
be given for this purpose, either morphine hypodermically, 
or laudanum by enema. The most useful preparation in 
such casrs is perhaps the extract of opium, which should 
be given in doses of 1 \ to 'I grains in pills. This not only 
quiets the movements of the intestine, but it appears also 
to have a general hemostatic action ; it is as useful in hem- 
optysis as in gastro-intestinal hemorrhages. 

The perchloride of iron is much employed, although its 
internal hemostatic effect has been doubted. It may be 
given in doses of 15 to 60 minims in divided portions, to 
which a drachm of Rabel water may be added. Rabel 
water contains ion parts of sulphuric acid to 300 parts of 
ninety-per-cent alcohol; it is thus a sulphate of ethyl. 
Perchloride of iron and sulphuric acid, as well as the dif- 
ferent tannic astringents, should not be employed in cases 
of gastric hemorrhage due to ulcer, because they might 
increase directly the acidity of the stomach or stimulate 
the secretion of h} T drochloric acid. 

If the means just indicated do not suffice to arrest the 
hemorrhage we may resort to ergot or its derivatives, er- 

226 



GASTRIC AND INTESTINAL HEMORRHAGE. 227 

gotin or ergotinin. We may give from | to 1 drachm 
of Bonjean's ergotin in a solution which is to be taken in 
tablespoonful doses during the twenty-four hours. For 
hypodermic injection we prefer Yvon's ergotin or Tanret's 
ergotinin to Bonjean's preparation. Yvon's ergotin cor- 
responds to an equal weight of ergot. Tanret's ergotinin 
is administered in doses of ^hr to ■£$■ grain. 

Hemorrhages from the stomach or intestine may be so 
profuse as directly to endanger the life of the patient, and 
it may be necessary to combat the acute anaemia, resulting 
from this loss of blood, by transfusion. In the place of 
transfusion of blood we may give hypodermic injections 
of artificial serum in doses of from 2 to 7 ounces at least. 
This is an excellent means of improving the heart's action. 



PART IV. 

DISEASES OF THE STOMACH AND INTESTINE 

The details upon which we have dwelt a jjtojdos of the 
treatment of the different varieties of dyspepsia and of the 
symptoms met with in diseases of the stomach and intes- 
tine will help us greatly in our study of the treatment of 
those diseases which have a definite anatomical hasis. 

The diseases of the stomach the special therapeutic 
management of which we are about to consider are the 
following : 

Gastritis. 

Simple ulcer and ulcerative gastritis. 

Cancer. 

Among the diseases of the intestine we shall take up the 
treatment of the following: 

Enteritis. 

Dysentery. 

Typhlitis and appendicitis. 

Intestinal occlusion and obstruction. 

Cancer of the intestine. 

Intestinal parasites. 

The treatment of gastric and intestinal hemorrhage has 
been studied in a previous chapter. 

228 



CHAPTER 1. 
GASTRITIS. 

The term gastritis has been greatly abused in the past, 
and still is. Many who are even yet under the influence 
of Broussais regard inflammation as the basis of dyspep- 
sia, while others, on the contrary, look upon the nervous 
element as the predominating one. This is hardly the 
place to enter upon theoretical discussions, but nevertheless, 
as the treatment must be founded in great measure upon 
etiological considerations, we think it well that there should 
be no misunderstanding as to what we conceive to be the 
relation between dyspepsia and gastritis. 

While we are persuaded that dyspepsia may exist with- 
out gastritis, we yet believe that inflammation of the stom- 
ach may be in certain cases the primary lesion, and that it 
may also be superadded to what is at first a purely nervous 
dyspepsia. Very often, however, we can hardly determine 
which of the symptoms are referable to inflammation of 
the mucous membrane of the stomach, and we ought not 
to pay undue attention to it in our considerations of treat- 
ment. The certainty of the existence of diffuse gastritis 
would not add much to the indications already present and 
would hardly lead us to modify in any important particu- 
lar our therapeutical conduct of the case. The fact of gas- 
tritis being present would have a greater bearing upon the 
prognosis than upon treatment. Nevertheless the exist- 
ence of gastritis may occasionally furnish some indications 
of value, otherwise there would be absolutely no use in de- 
voting a special chapter to its consideration. 

The inflammations of the stomach may be divided into 
acute and chronic; and acute and chronic gastritis may 
be further subdivided according as we regard the condi- 

229 



230 DISEASES OF THE STOMACH AND INTESTINE. 

tions from a point of view of etiology or of pathological 
anatomy. 

According to their intensity we shall divide the acute 
forms of gastritis into mild and severe ; and the chronic 
forms into gastritis with hypersecretion of mucus, gastri- 
tis with hypersecretion of hydrochloric acid, atrophic gas- 
tritis, and submucous gastritis with hypertrophic sclerosis. 
We might add ulcerative gastritis, but it is more natural 
to consider the treatment of that in connection with simple 
ulcer of the stomach. We may also distinguish between 
primary and secondary gastritis, according as the inflam- 
mation will explain the greater part of the symptoms ob- 
served or as the morbid state is dominated completely by 
a lesion or a disease of which the gastritis is the conse- 
quence. We shall not concern ourselves particularly with 
these secondary forms of gastritis. 

Finally, gastritis ma}' be secondary to other diseases of 
the stomach, such as atonic dilatation with stagnation of 
the stomach contents, dilatation of mechanical origin, can- 
cer, etc. In these conditions it always aggravates the pri- 
mary state. 

A I cute Gastritis. — The older writers looked upon a great 
number of distinct affections as varieties of gastritis or 
gastro-enteritis. Their view of the case was much too 
simple a one, for in reality the matter is extremely compli- 
cated. And now that we have learned to distinguish many 
other elements, such as auto-intoxications, the role of the 
nervous system, etc., we are greatly embarrassed to deter- 
mine just where the symptoms attributable to gastritis, to 
acute gastritis in particular, begin. Dyspepsia and acute 
indigestion were formerly regarded as acute gastritis; is 
this condition present in the indigestion and gastric intol- 
erance following alcoholic excesses? Possibly; but if it 
is, the lesion is a superficial and temporary one and quickly 
curable. 

Acute gastritis is much more easily diagnosed when the 
inflammation is severe than when it is mild. The symp- 
toms of toxic gastritis are verj- intense. After the inges- 



GASTRITIS. 231 

tion of an irritant poison, such as an acid or alkali in con- 
centrated solution, there are repeated attacks of vomiting, 
sometimes of blood, severe pain occurring spontaneously, 
or provoked b}^ palpation of the epigastric region, a small 
and rapid pulse with an anxious face, drawn, and covered 
with sweat. We think that a certain diagnostic impor- 
tance should be attached to the tenderness on pressure over 
the epigastric region and especially along the greater cur- 
vature of the stomach. 

The presence of acute inflammation of the stomach affords 
an indication for absolute rest of the organ. During the 
first few days of a hyperacute toxic gastritis, hypodermics 
of morphine must be given to quiet the pain and to restrain 
the movements of the stomach, ice should be applied over 
the epigastric region, and we must restrict, as far as pos- 
sible, the amount of fluid introduced into the stomach. 
We may give small pieces of ice to moderate the thirst, but 
it is better to give small enemata, which the patient must 
endeavor to retain, in order to supply to the organism the 
amount of fluid that it needs. In very grave cases we 
may have recourse to hypodermoclysis. 

In less severe cases, or after improvement has begun, 
the patient should be placed upon a milk diet and should 
take alkalies in large doses ; the management of the case 
is very much the same as that suitable to ulcerative gas- 
tritis ; as a sedative we may give a little opium or morphine. 

In very mild cases, which are destined to recover soon, 
rest to the organ at the beginning, consequently abstinence 
from food, and then a milk diet with the gradual addition 
of bland food, alkaline waters, and hot drinks will fulfil 
satisfactorily every indication. 

Of suppurative gastritis, which is a very rare condi- 
tion, we shall sa3" but a word. It is an exceedingly grave 
disease, which often develops with general symptoms of 
great severity, the diagnosis of which is difficult. It 
should be treated in the same way as a hyperacute toxic 
gastritis. The fever and the typhoid symptoms are chiefly 
to be combated. 



232 DISEASES OF THE STOMACH AND INTESTINE. 

Chronic Gastritis. — The presence of mucus in the 
vomited matters has long been considered as characteristic 
of catarrhal gastritis. The mucous glands in the epithe- 
lial coat of the stomach may, in cases of mild, superficial 
inflammation, pour out a considerable quantity of mucus. 
In more severe and more deeply seated cases the principal 
(adelomorphous) cells themselves may undergo mucous 
transformation and also furnish their contingent of mucus. 
On the other hand, the border or delomorphous cells would 
betray their excitement by an exaggerated secretion of 
hydrochloric acid. Thereare, therefore, two varieties of 
chronic catarrhal gastritis, mucous and acid. There may 
also be an atrophy of the glandular elements— atrophic 
gastritis — and finally submucous hypertrophic sclerosis, 
the plastic linitis of Brinton. 

Gastritis with Hypersecretion of Mucks. — There is no 
question as to the hypersecretion of mucus in many cases 
of chronic gastritis, but the presence of this substance is 
not always easy of demonstration. A certain amount of 
ropiness of the vomited matters is not necessarily due to 
the presence of gastric mucus, for the slownessof filtration 
of the gastric juice maybe due t-> the presence of dissolved 
albumins. Finally it is difficult t<> determine how rich 
the gastric juice is in mucus merely from the opalescence 
due to the precipitation of mucin by acetic acid. An ex- 
cessive secretion of mucus does not preclude a hypersecre- 
tion of hydrochloric acid, and on the other hand it may go 
along with a diminished secretion of this acid. The mucus 
disappears when there is complete atrophy of the mucous 
membrane. That would be a sign of very grave prognos- 
tic import. From what we have said, therefore, chronic 
gastritis may coexist with all the chemical varieties of 
dyspepsia. 

In general this condition calls for no special treatment 
directed to itself alone. The excess of mucus, however, 
is regarded as harmful, for it coats the particles of food 
with a sort of varnish which isolates them and renders 
them rebellious to the action of the gastric juice. For this 



GASTRITIS. 233 

reason attempts have been made to prevent the excessive 
secretion of mucus by means of alkaline waters, taken in 
the form of beverages or used in lavage. Lavage of the 
stomach certainly is of benefit when there is at the same 
time an exaggerated secretion of mucus and a tendency to 
stagnation of the contents of the stomach. The lavage in 
such cases should be made with alkaline water. 

Gastritis ivith Excessive Secretion of Hydrochloric 
Acid. — Whether gastritis exists or not, the treatment of 
hyperchlorhydria is always that which we have indicated 
above ; and the reader is referred to the instructions there 
given. 

Atrophic Gastritis. — Every severe and long-continued 
inflammation of the stomach tends to produce atrophy of 
the mucous membrane and dilatation of the organ; in this 
way are produced those cases of extreme dilatation, the 
treatment of which we have already discussed. We must 
not forget that pernicious anaemia has been referred to 
atrophic gastritis as its cause. 

Gastritis with Submucous Hypertrophic Sclerosis. — 
It is sometimes very difficult to distinguish the symptoms 
of this condition from those of cancer of the stomach, and 
the diagnosis is not always easy even on the post-mortem 
table or under the microscope. The gravity of the affec- 
tion is hardly inferior to that of cancer and its treatment 
would be the same. 



CHAPTER II. 
SIMPLE ULCER AND ULCERATIVE GASTRITIS. 

We shall not here discuss the numerous and diverse 
theories which have been offered in explanation of the pro- 
duction of simple ulcer of the stomach, 1 for we think that 
the subject does not admit of discussion. The doctrine to 
which we hold is that of gastritis as put forth by Cru- 
veilhier. The presence of gastritis in these cases has been 
demonstrated by Laveran, Galliard, Jaworski and Korck- 
zinski, and ourselves. However, this in itself is not suffi- 
cient to give rise to an ulcer, and there are other conditions 
which are indispensable in order that an ordinary simple 
gastritis may pass into ulcer of the stomach. The inflam- 
mation must be patchy in character and not uniformly in- 
volving the mucous surface; if the mucous membrane 
between these patches is healthy or but little affected it 
will continue to furnish an active gastric juice; this will 
act upon the spots of inflammation where there is a collec- 
tion of embryonal elements possessing but slight vital re- 
sisting power. Furthermore, there is in a great majority 
of cases of ulcer of the stomach an increased secretion of 
hydrochloric acid, and this renders auto-digestion of the 
affected portions of the mucous membrane still more easy 
and probable. The coexistence of hyperchlorhydria and 
of a real gastritis is the most frequent pathogenic condi- 
tion of simple ulcer, and it makes little difference whether 
the hyperchlorhydria or the gastritis is the first in point 
of time. 

Ulcerative gastritis differs from simple ulcer in that 

1 See Debove and J. Renaut : " Ulcere de l'Estomac, " Bibliotheque 
Charcot- Debove, 1892 ; Albert Matthieu : "Pathogenie et Traitement 
de TUlcere de l'Estomac," Gazette des Hopitaux, 906, 1892. 

234 



SIMPLE ULCER AND ULCERATIVE GASTRITIS. 235 

there is little or no auto-digestion. The gastritis is much 
more extensive and deeper and the ulcerations result from 
inflammatory action entirely; there is an excessive de- 
squamation of the epithelium, and the embryonal elements 
which accumulate in the mucous membrane become disin- 
tegrated and are rubbed off. As a result of this process 
we see extensive, irregular, and disseminated losses of sub- 
stance. Ulcerative gastritis is essentially a gastritis which 
has lasted for a long time, being maintained by the con- 
stant repetition of the same causes, the abuse of alcohol, 
for example. Although it is difficult to define the limit 
between ulcerative gastritis and simple ulcer, there is, nev- 
ertheless, a very appreciable difference as regards patho- 
genesis, the nature of the affection, its evolution, and the 
extent of the lesions. As we shall see later, there is much 
less difference in the treatment of the two. 

In a case of simple ulcer, which, as we have said, results 
from the auto-digestion of inflamed spots of the mucous 
membrane, the lesion is clean-cut as with a punch and 
gen erally more or less rounded. Hemorrhage or perfora- 
tion may occur very early. The pain is usually quite se- 
vere, and this is an advantage because it obliges the patient 
to seek medical advice, and then, thanks to the regime in- 
stituted, further inflammation and destruction of the mu- 
cous membrane are arrested. The mucous membrane may 
be eaten away at several points, but the ulcer is not rarely 
single, for the simple reason that the intensity of the symp- 
toms forces the patient to submit to treatment. We see 
what clear indications for treatment this simple and satis- 
factory theory of ulcer of the stomach offers, and how well 
it explains the good results obtained by a milk diet and 
the administration of alkalies. 

The principal symptoms of ulcer of the stomach are pain 
coming on after the ingestion of food or drink, a pricking 
pain, pain excited by pressure over the epigastrium, and 
vomiting, especially vomiting of blood. The hematemesis 
accompanying ulcer of the stomach is ordinarily abundant. 
The blood is usually unaltered. It may also, when the 



236 DISEASES OF THE STOMACH AND INTESTINE. 

hemorrhage has been profuse, be found in the stools as 
mehena. Certain symptoms attributed to ulcer are in 
reality due to the concomitant hyperchlorhydria, especially 
the pain coming on three or four hours after eating, which 
has been supposed by some to be a sign of the pyloric seat 
of the ulcer. 

The peptic ulcer may be situated in the lower part of the 
oesophagus, near the cardia, or in the first part of the duo- 
denum, between the pyloric valve and Vater's ampulla. 
It is, when situated in either of these two places, of exactly 
the same nature as the gastric ulcer, but the symptoms are 
somewhat different. An ulcer in the lower portion of the 
oesophagus causes pain at the end of deglutition; the pas- 
sage of a sound, which is dangerous, however, permits us 
to determine its exact location. In the case of ulcer of the 
duodenum the spontaneous pa in occurs late and that which 
is provoked by pressure is fell below and to the right of 
the hollow of the epigastrium. This duodenal ulcer often 
gives rise unexpectedly to very prof use hemorrhages, which 
may even endanger life; the blood may flow back into the 
stomach, but usually it is wholly evacuated through the 
bowels. 

We shall take up first the question of the treatment of 
the ulcer itself, and then of that of its complications, that 
is to say, hemorrhage, vomiting, and perforation of the 
stomach. 

To Cruveilhier is due the merit, not only of distinguish- 
in- simple ulcer from cancerous lesions of the stomach, but 
also of establishing the value of a milk diet in the treatment 
of this affection. His object was to obtain as complete rest 
as possible for the organ. This is indeed an indication 
which should be met in ail cases, and we should endeavor 
to secure rest, not only of the motor, but of the secretory 
functions. The theory of auto-digestion has brought for- 
ward another indication, that of neutralizing the gastric 
juice in order to render it inactive. 

There is no more radical means of obtaining this end 
than absolute abstinence from food. The water necessary 



SIMPLE ULCER AND ULCERATIVE GASTRITIS. 237 

for the organism should be introduced subcutaneously or 
by the rectum . We may give each day several small ene- 
mata of boiled water of, say, three or four ounces each, so 
as to secure the absorption of about a pint a day. If the 
patient cannot retain these enemas we must resort to subcu- 
taneous injections of sterilized water, or, better yet, of a 
0.5-per-cent solution of chloride of sodium. 

Nutrient enemata of peptone, milk, or yolk of egg have 
been recommended, but we do not regard them as of much 
value. The peptone is often badly borne; the milk and 
yolk of egg may be better tolerated, but even the} 7 are often 
irritating to the rectal mucous membrane, in which case 
injections of simple water are much preferable. If only 
the patient receives a sufficient quantity of water, a fast 
of several daj^s' duration is void of danger. We might 
try the addition of the yolk of an egg to each of the ene- 
mata, or even give injections of two or three ounces of milk 
of beef tea with one-half to one ounce of brandy. But we 
must not insist upon these if they are not well tolerated. 

The patient should remain absolutely quiet in bed in 
severe cases in which there is excessive pain, repeated 
vomiting, and profuse hematemesis. Laudanum by enema 
or hypodermics of morphine may be given to secure, as far 
as possible, absolute rest of the stomach. The precautions 
taken should be the same if we have reason to fear perfo- 
ration. 

We must reduce the secretion of the gastric mucous 
membrane to its minimum, with which object we should 
forbid solid food and irritating drinks, putting the patient 
on a milk diet. This is absolutely necessary at the begin- 
ning of the trouble. Milk is a complete food, as little ir- 
ritating as possible, which neutralizes the free hydrochloric 
acid of the gastric juice. This theory explains admirably 
the good results obtained by its use in practice. The milk 
should be given in small quantities at intervals ; it should 
be cold, boiled or raw, not sweetened, and should be given 
in the amount of about two quarts a day to begin with ; at 
the end of six or eight days the amount may be raised to 



838 DISEASES OF THE STOMACH AND INTESTINE. 

three quarts. It is well to add about three ounces of lime 
water to each quart of milk ; the lime water in this pro- 
portion has only a feeble alkaline action, nevertheless it 
appears to have an excellent effect on the pain. 

The disadvantage of milk is that it is an aliment very 
rich in fat, sufficiently rich in nitrogenous substances, but 
poor in carbohydrates. An adult requires a considerable 
amount to maintain nutrition (about six quarts) which 
cannot be taken continuously without incurring the risk of 
dilatation of the stomach. An exclusive milk diet is good 
enough for the first week or two of treatment, but after that 
it becomes insufficient. For this reason Debove suggests 
the addition of food powders, especially meat powder. At 
the end of the first week of treatment by milk alone we may 
give each day one, then two, and finally three ounces of meat 
powder in water or milk, flavored with a little peppermint. 
We ought not to add any rum or brandy as we would in the 
case of tuberculosis. The amount of meat powder may be 
increased gradually up to three, four, or even seven ounces 
a day, but unfortunately it is often difficult to make the 
patients take such a considerable volume of this substance. 
When the patient acquires such a disgust for this food as ab- 
solutely to refuse it, we must have recourse to the stomach 
tube. The tube should be introduced only with great care, 
after painting the pharynx, if necessary, with e< tcaine. It is 
not necessary to pass it into the stomach, but we may stop 
half-way down the oesophagus. We must avoid as far as 
possible exciting the stomach "to contraction or increased 
secretion and, before all, we should not irritate the mucous 
membrane directly by a foreign body. When it is found 
that the sound can be introduced without much trouble, it 
may be used for the introduction of alkalinized meat pow- 
der once or twice a day. This method of gavage gives 
excellent and speedy results whenever it can be employed. 

Secretory repose of the stomach is obtained in a large 
measure by the use of milk, of meat powder, or of milk 
powder, but it is mainly obtained by neutralizing the acids 
in excess. Alkalies in large doses are to be administered 



SIMPLE ULCER AND ULCERATIVE GASTRITIS. 230 

in the manner described when speaking of hyperchlorhy- 
dria. At the beginning, when the patient is on an abso- 
lute milk diet with or without lime water, a small quantity 
(2^ to 4= drachms) of bicarbonate of soda a day will suffice. 
The soda may be simply added to the milk, or better, is 
given in powders dissolved in a little water or milk when- 
ever the pain reappears, as it tends to do when the neutral- 
izing effect of the milk on the gastric juice ceases. We 
may also give the powders regularly every hour. Debove 
gives from fifteen to twenty powders a day, each composed 
of 3 grains of prepared chalk and 10 of bicarbonate of 
soda. The two substances should be as intimately mixed 
as possible, so as to prevent the chalk from becoming caked 
and forming concretions in the stomach. 

The dose of the alkali should be increased when the pa- 
tient begins to eat again. We may then give from 5 to 8 
drachms of bicarbonate of soda, or an equivalent amount 
of some other alkali, according to the indications which we 
have laid down in discussing hyperchlorhydria. Debove 
gives one of the following powders every half-hour for the 
three hours after a meal : 

I£ Bicarbonate of soda, gr. xv. 

Prepared chalk, 
Calcined magnesia, . . . . aa gr. iij. 

That amounts to a dose of 1-J- drachms of bicarbonate of 
soda and of 18 grains each of prepared chalk and magnesia 
after each meal. When there is diarrhoea the chalk alone 
may be given, and when there is constipation the chalk 
may be omitted from the mixture. 

By means of this diet and medicinal treatment we have 
brought the patient to the time when he can take some- 
thing more than milk and powdered meat. He must still 
avoid everything that may irritate the mucous membrane 
of the stomach, conducting himself exactly as if he were 
suffering from hyperchlorhydria. Wine and alcoholic 
beverages are to be forbidden as well as highly seasoned 
food and irritating medicaments. The meat should be 



2-iO DISEASES OF THE STOMACH AND INTESTINE. 

well cooked and in a state of fine division, all the indi- 
gestible portions being carefully removed; vegetables 
should be given in the form of purees, and green vegeta- 
bles allowed only when convalescence is well established. 
The diet list of Leube may be consulted when the time 
comes for a gradual return to a normal dietary. We must 
never forget that relapses are very common in simple ulcer, 
doubtless because the tendency to hypersecretion of hydro- 
chloric acid persists. 

Pain is sometimes very severe in cases of gastric ulcer, 
but it often yields to neutralization of the gastric juice by 
alkalies and in that case no further medication is needed. 
Occasionally, however, this is not sufficient and then we 
must resort to direct sedatives, such as opium, morphine, 
chloroform water, cocaine, or extract of cannabis indica. 
For more explicit directions as to dosage and mode of ad- 
ministration the reader is referred to Chapter IV. of Part 
III., in which the treatment of pain is discussed. We 
must be careful about the hypodermic administration of 
morphine in these cases because of the facility with which 
such patients acquire the morphine habit. 

Occasionally the vomitin- is so persistent and frequent 
as to demand a special treatment in addition to that by 
alkalies and milk. Riviere's potion isnol admissible here 
because the evolution of carbonic acid gas to which it gives 
rise may occasion a dangerous distention of the stomach 
and thus lead to perforation. For the same reason all 
gaseous drinks should be forbidden. Lavage is also con- 
tra-indicated, as it may provoke hemorrhage as well as 
perforation. In cases of long standing in which no hem- 
orrhage has occurred for some time, we may try gavage 
which is often an excellent remedy against vomiting. One 
of the most simple means of quieting the stomach is to 
give little morsels of ice which should be swallowed whole 
and not allowed to dissolve in the mouth ; cold drinks may 
also be of service. If these measures do not suffice we 
must resort to the remedies above enumerated for the relief 
of pain. 



SIMPLE ULCER AND ULCERATIVE GASTRITIS. 241 

The list of substances which have been employed to com- 
bat vomiting is a very long one, and sometimes success has 
occurred most unexpectedly. Lasegue has given tincture 
of iodine, 15 drops in 5 ounces of sweetened water, a 
tablespoonful of which is taken every two hours. Debove 
and Renaut recommend hydrocyanic acid, 5 to 15 drops 
of a one-per-cent solution. 

Rosenheim has recommended the use of nitrate of silver 
in hypersesthesia of the mucous membrane, and we have 
several times obtained good results from its employment 
in obstinate vomiting. Two teaspoonfuls of a solution of 
two or three parts per thousand of distilled water may be 
given three times a day. Nitrate of silver has also been 
advised as a topical remedy to promote cicatrization of the 
ulcer, but it is difficult to see how this effect can be ob- 
tained, for it is probable that the salt is immediately de- 
composed in the presence of hydrochloric acid and the 
chlorides. If this be so, the only advantage of administer- 
ing nitrate of silver would be to neutralize a portion of the 
hydrochloric acid, an action which may well be ignored. 
Other substances which have been proposed for the pur- 
pose of causing cicatrization of the ulcer are of no more 
value than this. The whole list of so-called cicatrizing 
agents may therefore be dismissed as of no use whatever. 

Complications. — These are immediate, such as hema- 
temesis and perforation, and remote, such as dilatation of 
the stomach from cicatricial stenosis of the pylorus. The 
treatment of hemorrhage from the stomach is discussed in 
chapter XL of Part III. Properly speaking there is no 
medical treatment of perforation. When it occurs it leads 
at once to a hyperacute peritonitis of the most serious char- 
acter. The physician should know, however, when this 
accident occurs that the supreme resort is immediate lap- 
aratomy. If the surgeon could readily find the point of 
perforation, if the contents of the stomach had not been 
scattered over too great an extent of the peritoneal surface, 
it would not be impossible to cleanse the peritoneum, unite 
by suture the edges of the ulcer, and thus obtain cicatriza- 
16 



242 DISEASES OF THE STOMACH AND INTESTINE. 

tion. In the presence of the immense danger of perfora- 
tion the attempt to close the opening by suture would be 
justifiable. 

One of the most common and serious of the remote com- 
plications of gastric ulcer is cicatricial narrowing of the 
pylorus with consequent dilatation of the stomach. We 
have already considered this subject and must refer the 
reader to the chapter on dilatation. The only cure is a 
surgical one. Gastroenterostomy is the operation which 
appears to present the fewest dangers and to promise the 
best results. 



CHAPTER III. 
CANCER OF THE STOMACH. 

Notwithstanding the incurability of the disease, the 
phj'sician should not be discouraged when he finds him- 
self in the presence of carcinoma of the stomach, for he 
may often be able to render signal service to his patients 
in relieving some especially distressing symptom, in bring- 
ing up their physical strength and spirits, and in lessening 
their suffering. 

The medical treatment of the disease is unfortunately 
exclusively symptomatic. The remedies which have been 
vaunted one after the other as specifics have each in turn 
been shown to be worthless. The latest and the most cele- 
brated of these was condurango; this drug came from 
South America with the reputation of being a cure for 
cancer, which was credited at first by many even excellent 
physicians who were led for the moment to believe that 
they had actually witnessed one or more cures of carci- 
noma. But this triumph was short-lived, and condurango 
soon fell back into the rank of simple stomachics, perhaps 
even of the second order. Let us see what are the symp- 
toms which we may hope to relieve in a measure by our 
intervention. 

A milk diet is eminently serviceable in a large number 
of cases, as this is the food which the patients usually tol- 
erate the best. Under the influence of milk we may see 
vomiting cease, pain grow less, and the general strength 
improve, the amelioration being sometimes so marked as 
to lead the medical attendant to suspect the correctness of 
his previous diagnosis. The addition of a little lime water 
to the milk will often cause it to be better borne by the 

343 



2U DISEASES OF THE STOMACH AND INTESTINE. 

patient. In certain cases we may try gavage with meat 
powder, eggs in various shapes, milk soups, purees, and 
some of the numerous nutritive powders that are on the 
market. It is not often, however, that this varied diet 
can be continued for a long time, and we are generally 
forced to return to the milk. 

Anorexia is common in cases of cancer of the stomach, 
and is rather difficult to overcome with the ordinary reme- 
dies such as mineral waters, bitters, or acids, especially 
hydrochloric acid. A better result is sometimes obtained 
by lavage. It is not uncommon to find dilatation with 
stasis as a complication, especially when the lesion is sit- 
uated near the pylorus with consequent narrowing of this 
orifice. Solid and liquid food and the various products of 
secretion accumulate in the stomach and undergo organic 
fermentation. In such cases vomiting ordinarily super- 
venes at the end of a few days and the patient expels in 
mass all that lias been accumulating in the stomach. But 
this result is more quickly and better obtained by lavage. 
The stomach may be washed out with simple boiled water 
or with any of the antiseptic solutions previously men- 
tioned. We may by this means spare the patient the feel- 
ing of malaise which an overloading of the stomach causes, 
the fatigue of vomiting, and the pain excited by contact 
with a superacid fluid, and we may also in a certain mea- 
sure prevent the auto-intoxication due to abnormal fermen- 
tation. 

In most cases of carcinoma there is a marked diminu- 
tion or actual suppression of hydrochloric acid, and this is 
an additional cause of the secondary fermentation of the 
retained contents of the stomach. The attempt has natu- 
rally been made to supply artificially the missing acid, but 
without much success, it must be confessed. I formerly 
gave hydrochloric acid in these cases, without seeing any 
marked benefit from its use, but have recently abandoned 
it, being led to this by a consideration of what occurs after 
gastroenterostomy in cases of cancer of the pylorus. The 
operation does not cure the disease, but it does often bring 



CAXCER OF THE STOMACH. 245 

about a very noticeable improvement in the local and gen- 
eral conditions, showing what an important part the pyloric 
stenosis plays in the production of many of the symptoms. 
But furthermore, curiously enough, the pain also disap- 
pears. This is to be explained by the fact that the stomach 
contents no longer come in contact with the cancerous 
ulceration, but pass directly into the small intestine along 
the new route opened up by the operation. One of the 
most important indications is, therefore, to relieve the stom- 
ach of its overload and to render its contents less irritating 
by reducing their acidity. It is evident that this can be 
done better by lavage and the administration of alkalies 
than by the exhibition of hydrochloric acid. 

With the object of reducing gastric fermentation we may 
give chloroform water, sulphocarbonated water, naphthol, 
or a solution of boric acid. We must not forget that can- 
cer of the stomach can hardly exist without an extensive 
gastritis, and that certain antiseptics are very irritating to 
the inflamed mucous membrane. A saturated solution of 
boric acid appears to do well in these conditions ; it may 
be administered in doses of 5 to 10 ounces a day. 

The imperfect elaboration of the food and the more or 
less impermeability of the pylorus may be the occasion of 
actual inanition. This might be easily obviated if we 
could but fabricate peptones and other products of artificial 
digestion which would be directly assimilable, but unfor- 
tunately peptones are not usually well borne and often 
cause vomiting or diarrhoea. The attempt has been made 
to nourish the patient by the rectum. We can easily effect 
the absorption of five or ten ounces, or even more, of water 
through this channel, but it is much more difficult to get 
the patient to tolerate peptones, eggs, milk, or more or less 
concentrated bouillons which have been given as nutrient 
enemata. A little brandy may sometimes be absorbed by 
the rectum and is useful as a tonic. We may also give 
caffeine or phosphate of soda by hypodermic injection for 
tonic purposes. 

The pain accompanying cancer of the stomach is some- 



246 DISEASES OF THE STOMACH AND INTESTINE. 

times atrocious. We have shown how much relief can be 
afforded in certain cases by lavage and the administration 
of alkalies, and when these do not suffice we must resort 
to the ordinary analgesics. In these cases we may give 
opiates without reserve, for there is no such reason to fear 
the establishment of the opium habit here as there is in 
simple ulcer. 

The mechanism of the vomiting is not always the same 
in all cases. We have already spoken of the emesis occur- 
ring as a relief to a surcharged stomach ; this is exceed- 
ingly copious and recurs at rather long intervals. Some- 
times vomiting comes on at the end of an attack of severe 
pain ; this is, without doubt, of reflex origin and is produced 
in the same way as the emesis of simple ulcer or of hyper- 
chlorhydria. In other cases there are attacks of acute indi- 
gestion which terminate in vomiting; these are amenable 
to treatment by lavage. The reflex vomiting which ac- 
companies the painful crises is to be treated by analgesics, 
cracked ice, chloroform water, carbonated beverages, etc. 

Gastrorrhagia calls for the ordinary treatment of hemor- 
rhage. 

In conclusion we may say a few words concerning the 
surgical treatment of carcinoma of the Btomach ; this may 
be curative or palliative in its aim. A curative treatment 
should be undertaken deliberately in only a ver}' small 
number of cases. In order that intervention may have 
any chance of success it must be done very early, and the 
cancerous lesion must be removed in its incipiency before 
it has had an opportunity to invade much of the stomach 
tissue and before there is any secondary adenopathy. Un- 
fortunately the diagnosis is usually made too late, and 
when laparatomy is performed we find ourselves in the 
presence of extensive adhesions, of a more diffuse lesion 
than we had anticipated, and of already implicated glands. 

The palliative operation (gastroenterostomy), which 
consists in establishing a communication between the py- 
loric end of the greater curvature of the stomach and a loop 
of the neighboring portion of the intestine, is more often 



CAXCER OF THE STOMACH. 247 

realizable. We have already shown how great an amelior- 
ation of all the symptoms may follow this operation, but 
it is unfortunately at the best only palliative and we can 
never hope to obtain a permanent cure by this means. 

All this is little encouraging, it is true, but, as we said at 
the beginning of this chapter, it is the duty of the physi- 
cian to struggle as best he can against the progress of the 
disease. He will always be able to help his patients, and 
that is something. Furthermore, the diagnosis of cancer 
is sometimes wrongly made and we may occasionally ob- 
tain a cure most unexpectedly. This is worth bearing in 
mind, for a case of this nature which would almost inev- 
itably die if left alone may possibly recover as a result of 
active and methodical treatment. We should always act 
as if we were in the presence of one of these cases of false 
cancer. 



CHAPTER IV. 
ENTERITIS. 

What we have said concerning gastritis is equally ap- 
plicable to enteritis. If the former has been considered 
the sole cause of dyspepsia so has the latter been regarded 
as a synonym of diarrhoea ; this is a double error, since 
every diarrhoea does not rest upon enteritis as a cause nor 
does every case of enteritis have diarrhoea as a symptom. 
While diarrhoea is common in acute enteritis, constipation 
is more frequent in the chronic form. Many of the rules 
for the treatment of enteritis will be found given in the 
chapters on diarrhoea, constipation, and intestinal antisep- 
sis. Space will permit us to consider here only a few 
complementary indications furnished especially by the dif- 
ferent clinical forms of intestinal inflammation. 

Let us consider first what are the symptoms by means 
of which, according to Nothnagel, we ma}' locate the seat 
of the inflammation. When the scybala are coated with 
mucus there is an inflammation of the descending portion 
of the large intestine. Mucus, when present in the form of 
whitish fragments or of more or less extensive membranes, 
indicates a chronic muco-membranous colitis. If the mu- 
cus is intimately mixed with soft or watery discharges, 
the inflammation probably reaches as far as the csecum. 
The presence of pure bile is a sign of extensive inflamma- 
tion of the small intestine. This bile often stains the clots 
of mucus, epithelial masses, or crystals. As a rule, blood 
is an indication of ulceration if it is found mixed with the 
intestinal discharges. Pus is usually disseminated among 
the other contents of the bowel, and its presence unmixed 
with the fsecal matters is an indication of its origin in the 

248 



ENTERITIS. 249 

lower part of the large intestine. Ulceration is accom- 
panied by constipation as often as it is by diarrhoea. 

Speaking generally, the part of the intestine affected by 
enteritis may be reached by remedies given b} r the mouth 
or by the rectum. The colon alone is capable of being 
affected by substances introduced into the rectum and is 
often thus modified in a very remarkable way. This is 
one reason for considering apart the treatment of dysentery 
and of dysenteric diseases. In the chapter on intestinal 
antisepsis we have already given directions which are espe- 
cially applicable to direct antisepsis of the large intestine. 

Acute Enteritis. — The cause of the affection (cold, ex- 
cess in eating, improper food, or the ingestion of irritating 
substances of various kinds) will furnish a most valuable 
therapeutic and prophylactic indication. The treatment of 
acute enteritis may be divided into two stages. We should 
first give a saline purge and then opium, subnitrate of bis- 
muth, prepared chalk, and sometimes antiseptics, such as 
salol, salicylate of bismuth, and preferably again benzo- 
naphthol. In very severe cases absolute rest must be en- 
joined. For the relief of intestinal pain we may apply 
poultices containing laudanum and give opiates internally. 
The diet should consist wholly of milk at first, but later 
boiled eggs and a moderate amount of food, containing but 
little indigestible residue, may be allowed. The necessary 
precautions against relapses, which occur so readily, should 
be taken. 

Chronic Enteritis. 1 — In the sections on diarrhoea, con- 
stipation, and intestinal antisepsis we have already indi- 
cated the therapeutical measures to be employed in chronic 
enteritis ; the treatment will vary according as diarrhoea 
or constipation is the predominating condition ; intestinal 
antisepsis is called for especially in cases of habitual diar- 
rhoea or when diarrhoeal attacks complicate chronic con- 
stipation. For the special treatment of the enteritis itself 
a course at some purgative spa is often advised. The diet 

J See the treatment of muco-membranous colitis in Chapter V., 
Part III. 



250 DISEASES OF THE STOMACH AND INTESTINE. 

is to be regulated upon the principles which we have al- 
ready explained. 

In chronic ulcerative enteritis, of which tubercular en- 
teritis is the type in our climate, diet holds the first place. 
When diarrhoea is present we must have recourse to a milk 
diet, raw meat, or food powders. Nitrate of silver in pill 
form, in doses of £ to 1-j grains a day, has been recom- 
mended for the cure of the ulcers, but it is very difficult to 
understand how the remedy can promote cicatrization 
when it is impossible for it to reach the seat of the lesions 
in its natural state ; nevertheless good results have occa- 
sionally been found to follow its administration. When 
the symptoms point to the colon as the location of the 
trouble we may employ astringent enemata and lavage of 
the large intestine. 

In tropical regions chronic diarrhoea assumes an intens- 
ity which is hardly ever seen in northern countries. Ob- 
servers do not agree as to the nature of the diarrhoea met 
with in the extreme East (Cochin China). Some regard 
it as essentially a dysentery, while others believe that it is 
a distinct affection caused by a special organism. For 
others again it is the common result of all the numerous 
and active causes of diarrhoea in warm countries. One 
common element in the causation is malarial infection. 
We may say here that chronic diarrhoea of malarial origin 
is by no means uncommon, and that in individuals suffer- 
ing from paludic infection we often see a diarrhoea of long 
standing yield to quinine when it has resisted all other 
forms of treatment. 

In cases of diarrhoea of warm countries and similar af- 
fections iu our own climate we should prescribe an absolute 
milk diet, opium at the beginning and later benzonaphthol, 
salicylate of bismuth, salol, lactic acid, and astringent or 
antiseptic enemata, the formulae for which we have pre- 
viously given. Convalescents should be Avatched with 
particular care as regards both diet and hygiene, because 
of the great tendency to relapse. 



CHAPTER V. 
DYSENTERY. 

Dysentery is an infectious and contagious disease, often 
occurring as an epidemic, common and severe in hot cli- 
mates, and of which the lesions are located in the large 
intestine, especially in its lower part. The symptoms of 
the various acute forms may differ greatly from each 
other ; the disease my become chronic. 

Very many modes of treatment have been employed, 
some of which have produced results so favorable that they 
have become in a measure standard ; these are the ones 
which we shall discuss in the present chapter. The treat- 
ment is based upon certain principles of which we ought 
not to lose sight. We must not forget, for example, that 
the diarrhoea is only apparent, and that in reality consti- 
pation is present in dysentery ; the profuse discharges are 
composed of the secretions from the inflamed or ulcerated 
mucous membrane ; true faecal stools are absent or are rep- 
resented, only by a few scattered, hard, broken masses. It 
is, therefore, a great mistake to treat dysentery as one 
would a diarrhoea and attack it with opiates, subnitrate of 
bismuth, or astringents administered by the mouth. 

Purgatives are the remedies indicated in dysentery, es- 
pecially, it would seem, cholagogue purgatives, 1 for it has 
been remarked that dysenteric stools contain no bile and 
that the return of this secretion is of excellent augury. 
Purgatives of the most various kinds have been vaunted, 
such as tamarinds, manna, cream of tartar, alkaline salts, 
Rochelle salt (potassium sodium tartrate), and rhubarb. 
But all these are inferior to calomel, which may be given 

1 Dujardin-Beaumetz : "Legons de Clinique Therapeutique, " 
"Traitement des Maladies de rintestin," p. 659, 1880. 

251 



252 DISEASES OF THE STOMACH AND INTESTINE. 

in a single large dose of 6 to 15 grains or in ten divided 
doses of J grain each. 

Ipecac is, however, the remedy which has been most 
highly recommended in the treatment of dysentery. It 
may be given by what is called the Brazilian method. An 
infusion is made of 2 drachms of pounded ipecac root in 6 
ounces of water ; this is filtered and taken in tablespoonf ul 
doses during the first day. The following day the same 
ipecac is again infused in an equal amount of water and 
administered in the same way. The third day the ipecac 
which has already served twice before is once more infused 
in 6 ounces of boiling water; but this time the whole, 
ipecac and infusion, is taken during the course of the day. 
Delioux de Salignac has sought to simplify this method of 
administration in the following way : ( hie drachm of pow- 
dered ipecac is boiled for five minutes in 9 ounces of 
water; this is filtered and to it are added 1 ounce each 
of syrup of opium and cinnamon water. Of this mixture 
a tablespoonful is taken every hour. Segond combines 
ipecac and calomel in the following pills, which are much 
employed by naval surgeons: 

I? Powdered ipecac, gr. xij. 

Calomel gr. vi. 

Extract of opium, . . . . . gr. iss. 

Syrup of buckthorn, . . . . q. s. 

M. et ft. pil. no. xii. 

The root of ailanthus glandulosa has been recommended 
as a substitute for ipecac (Robert). In the way of local 
treatment astringent and antiseptic enemata of all kinds 
have been used ; among these are rhatany, solution of the 
subacetate of lead (I drachm to S ounces of water), nitrate 
of silver (3 to 7 grains to 6 ounces of water), iodine (tincture 
of iodine, %\ to 5 drachms, iodide of potassium, 8 to 15 
grains, and 8 ounces of water), boric acid (1 per cent), 
permanganate of potassium (0.2 per cent), and corrosive 
sublimate. Delioux de Salignac gives the following by- 
enema : the white of an egg is dissolved in 6 ounces of 
water and to it are added 7 grains of nitrate of silver and 



DYSENTERY. 253 

then an equal amount of chloride of sodium in solution. 
Bonamy gives from a grain to a grain and a half of sub- 
limate in eight ounces of water to which a little alcohol is 
added; this is used morning and night. 1 Naphtholated 
water may also be used by enema. In chronic cases we 
may employ benzonaphthol. 

A milk diet is absolutely indicated during the treatment 
of dysentery. 

1 Although no accident has been reported, we should fear to use 
injections containing such a large quantity of corrosive sublimate. 



CHAPTER VI. 
TYPHLITIS, PERITYPHLITIS, APPENDICITIS. 

Up to within a recent period physicians have held to 
the theory of stercoral engorgement in the production of 
typhlitis; according to this the accumulation and indura- 
tion of faecal matters in tlie cul-de-sac of the caecum cause 
distention and resultant inflammation. In proportion to 
the intensity of this inflammation and the individual sus- 
ceptibility of the peritoneum there arise symptoms of ster- 
coral typhlitis with caecal engorgement, perforation with 
limited peritonitis, iliac phlegmon, and occasionally gen- 
eralized peritonitis. These views are no longer held, and 
to-day it is even a question whether stercoral typhlitis ex- 
ists. Laparatomy has been performed in the early stages 
of supposed cases of typhilitis, and instead of a faecal accu- 
mulation in the inflamed caecum the operators have found 
inflammation and frequently perforation of the vermiform 
appendix. 1 

The caecum may certainly be inflamed independently, 
and it is possible that a collection of faecal matter may 
provoke or increase this inflammation, but there is no 
proof that the collection of symptoms to which the name 
of stercoral typhlitis had been given really corresponds to 
inflammation of the caecum secondary to an accumulation 
of scybala in its cavity. The place of the caecum has been 
taken by its appendix, and it is to inflammation and per- 
foration of the appendix that we must attribute the phe- 
nomena formerly ascribed to disease of the caecum. Quite 

1 Maurin: "Essai sur l'Appendiculite, " These de Paris, 1891; 
Talamon : "Appendicite et Perityphlite, " Bibliotheque Charcot- 
Debove, 1892. 

254 



TYPHLITIS, PERITYPHLITIS, APPENDICITIS. 255 

frequently the inflammation is caused by the penetration 
of a foreign body, a little ball of fsecal matter, into the 
cavity of the appendix. This foreign body may be the cause 
of quite violent pain due to the contractions of the appendix 
in its efforts to press back the fsecal plug into the csecum 
whence it came; this is what Talamon has called appen- 
dicular colic. The irritation arising from the presence of 
the faecal matter may determine a simple limited inflamma- 
tion of the walls of the appendix, a spontaneous cure of 
which is possible; this is called parietal appendicitis. In 
other cases the inflammation may be much more intense ; 
pus forms in the dilated appendix, the walls of the latter 
ulcerate, and perforation ensues. This perforative appen- 
dicitis may result in a circumscribed, possibly suppurative, 
peritonitis or in a hyperacute generalized inflammation of 
the peritoneum. 

Medical treatment was formerly the only one employed, 
and it was not until late in the course of the disease that 
surgical intervention was practised to give exit to purulent 
collections. At the beginning of the trouble, as soon as 
pain was felt in the iliac fossa, purgatives and antiphlo- 
gistics were given. Occasionally the purgatives employed 
were too energetic and only added to the dangers of per- 
foration and peritonitis. In addition to the exhibition of 
cathartics and enemata leeches and cataplasms were ap- 
plied. In most cases treated in this way recovery ensued ; 
but it cannot be doubted that many have been thereby 
pushed to a fatal issue which at the present day would be 
saved by surgical intervention or by a more rational medi- 
cal treatment in which purgation holds a less conspicuous 
place. It is a question with some whether medical treat- 
ment is proper in any case, and many agree with Keen 
that the first indication in a case of appendicitis is to call 
the surgeon. Others, among them Talamon, regard this 
doctrine as extreme and maintain that it is not logical to 
undertake a surgical operation which is still dangerous, 
notwithstanding the progress made in antiseptic methods, 
for the treatment of an affection which usually recovers 



256 DISEASES OF THE STOMACH AND INTESTINE. 

spontaneously. An operation is not necessary in cases of 
appendicular colic or of parietal appendicitis. 

It is not certain that such a thing as appendicular colic 
really exists, yet it is very possible. It is comparable in 
its mechanism as well as in its symptomatology to hepatic 
colic; following over-fatigue or exposure to cold, there is 
a severe pain appearing suddenly in the iliac fossa and un- 
accompanied by fever or any well-defined local phenomena; 
there is no tumor in the csecal region. The treatment of 
this condition should be conducted on the same plan as 
that of hepatic or of renal colic: hypodermic injections of 
morphine, poultices, warm baths, mild purgation, and rest 
in bed. 

In parietal appendicitis the condition is more serious; 
the pain at the outset is persistent and subject to exacer- 
bations, and sometimes there is a circumscribed swelling 
in the right iliac fossa ; there may also be a slight eleva- 
tion of temperature (101° to 102° F.). Medical treatment 
is permissible in this stage; it should consist in absolute 
rest in bed, the application of ten or twelve leeches to the 
iliac fossa, cold applications or poultices, and mild cathar- 
sis by teaspoonful doses of castor oil taken every hour till 
the desired effect is obtained. But before resorting to these 
simple measures which often result in a cure, we must be 
certain that the inflammation is limited in extent and that 
there is neither suppuration nor perforation. 

Laparotomy is indicated in hyperacute cases and when 
there are symptoms of generalized peritonitis. When the 
inflammation remains circumscribed and the purulent col- 
lection is encysted it is well to delay operative interference 
for a few daj\s. Treves says that we ought not to operate 
before the fifth day and Talamon holds that there is more 
safety in delaying for from eight to twelve days, a conclu- 
sion which he has drawn from the study of numerous sta- 
tistics. The advantage of delay would be to give time 
to the inflammation to limit itself and to save from opera- 
tion those cases which would recover under medical treat- 
ment. In a recent discussion before a Swiss medical 



TYPHLITIS, PERITYPHLITIS, APPENDICITIS. 257 

society 1 the almost unanimous expression was had that 
medical treatment should be preferred to surgical (Kocher, 
Huguenin, Wyss, Sahli). Absolute rest in bed and opiates 
should be the basis of treatment ; purgatives are contra- 
indicated because immobilization of the intestine is sought 
for. But surgical intervention is called for whenever pus 
is present. 

It is needless to say that many surgeons favor methodi- 
cal and early intervention, but, in the early stages we in- 
cline to the side of medical treatment, while admitting, of 
course, the utility and necessity of laparatomy in cases of 
perforation or suppuration. 

The aim of operative interference is : 

1. In case of perforation to cleanse the peritoneum from 
the intestinal contents which have escaped into its cavity 
and thus to prevent the occurrence of general peritonitis. 

2. In case of suppuration to evacuate the pus and to 
cleanse the cavity in which it had collected. 

3. In all cases to remove the affected appendix and 
thereby prevent relapses. 

Certain surgeons favor operation whenever it is certain 
that the appendix is diseased and threatened by suppura- 
tive inflammation. Talamon, as we have seen, raises 
strong objections against this view. It is allowable in 
cases of recurrent appendicitis to resect the appendix in 
the interval between two attacks in order to put an end to 
the series of inflammatory crises with their constant men- 
ace of perforation and of peritonitis or abscess. 

Since habitual constipation certainly plays an important 
role in the etiology of appendicitis, we ought always to 
treat this condition in order to prevent relapses. 

We have thus far spoken only of primary appendicitis, 
but we occasionally see cases of true secondary typhlitis, 
unaccompanied by any clear signs of appendicitis. For 
example, during the course of a typhoid fever, we occa- 
sionally observe that the pain in the iliac fossa becomes 
more intense than usual and that there is a swelling in 
1 Correspondenzblatt fur Schweizer Aerzte, No. 4, 1893. 
17 



258 DISEASES OF THE STOMACH AND INTESTINE. 

this region ; this inflammation may resolve under the in- 
fluence of rest and of emollient application, but it may re- 
sult in the formation of a peri-csecal abscess. Tubercular 
typhlitis, although rare, is occasionally encountered. 

In conclusion we may say that it has been shown at au- 
topsy that the caecum may become dilated, acquiring some- 
times very considerable dimensions. It is evident that 
fsecal masses might accumulate in this cavity and aid in 
exciting an inflammation there analogous to muco-mem- 
branous colitis. The treatment suitable for the latter con- 
dition would be indicated in these cases. 



CHAPTER VII. 
INTESTINAL OCCLUSION. 

The causes of intestinal occlusion are very numerous. 
We may distinguish : 1 

1. Causes acting externally to the intestine, such as 
strangulation by false ligaments, by rents or openings in 
the omentum or mesentery, or by diverticula, such as an 
elongated vermiform appendix ; internal hernias, or com- 
pression from tumors of various kinds. 

2. Strangulation of the intestine by torsion, knots, or 
sharp bends. 

3. Obstruction of the lumen of the intestine by biliary 
or intestinal calculi, by foreign bodies, or by fsecal accumu- 
lations. 

4. Obstruction of the intestine by itself — acute or chronic 
invagination and intussusception. 

5. Occlusion by lesions of the intestinal walls — cicatri- 
cial or cancerous stenosis. 

Sometimes the phenomena of intestinal occlusion arise 
without any appreciable material cause in consequence of 
a sort of paralysis of the wall of the gut — pseudo-strangu- 
lation. 

One may see from this enumeration of the causes of in- 
testinal occlusion that certain cases may be amenable to 
medical treatment, while others are not. Medical treat- 
ment may effect a cure when there is mechanical obstruc- 
tion, resulting from the presence of faecal masses or of 
calculi in the intestine ; the exhausted peristalsis may be 
aroused in such a way as to cause the expulsion of the ob- 
structing body and thus re-establish the permeability of 
the intestine. It may, by simply stimulating the intes- 

1 Courtois-Suffit : 'Traite de Medecine," vol. iii., p. 527. 

259 



260 DISEASES OF THE STOMACH AND INTESTINE. 

tinal movements, straighten out a bend or even a slight 
torsion and disengage an invaginated loop when the con- 
dition has not gone too far and when adhesive inflamma- 
tion of the peritoneum has not glued together too strongly 
the folds of the bowel. When there is a slight degree of 
stenosis, the obstruction may be caused by a faecal plug, 
the dislodgement of which may possibly be effected by 
more active peristalsis. The most striking results of 
medical treatment are seen in cases of obstruction due to 
weakness of the intestinal walls. It is absolutely useless 
when opposite conditions prevail, when the intestine is 
utterly exhausted or the obstacle is of such a nature as to 
be irremovable. It is in these cases that surgical inter- 
vention is indicated. 

Physicians should keep the principle constantly in mind 
that, while acting with sufficient energy, they must avoid 
wearing out the intestine by excessive stimulation and al- 
lowing the organism to become exhausted by pain, vomit- 
ing, or auto-intoxication. They should be ready to resort 
to surgical measures at a sufficiently early period while the 
patient's powers of resistance are still unexhausted and 
the lesion of the intestine and of its peritoneal coat is yet 
moderate in extent and degree. They should none the less 
insist upon a trial of medical methods whenever they find 
themselves in the presence of one of the conditions which 
we have indicated as favorable. It is j>roper to remark 
that it is often very difficult to arrive at an exact diagnosis 
of the nature, degree, and sometimes even of the seat of 
the lesions. The location of the lesion is a matter of great 
importance, for, in a general way, we may say that meas- 
ures bearing directly upon the large intestine (copious ene- 
mata, insufflations, etc.) will hardly succeed except when 
the colon is the seat of the occlusion. 

We cannot devote much space to the question of diag- 
nosis, although we may recall a few of the important prin- 
ciples. Invagination is much more frequent in children, 
while obstruction and cancer are common in the aged. 
The earlier vomiting occurs and the more frequent it is 



INTESTINAL OCCULSION. 261 

the higher up in the intestine is the occlusion. The bowels 
may move even after occlusion has occurred, but then only 
when it is located in the upper portion of the intestine. 
Bloody stools and rectal tenesmus are symptoms especially 
of invagination. The absolute suppression of the emission 
of gas has a much greater significance in the diagnosis of 
occlusion than has the persistence of the stools. Stercora- 
ceous vomiting is symptomatic, though not pathogno- 
monic, of intestinal occlusion. When the occlusion has 
its seat in the small intestine the tympanites occupies the 
middle portion of the abdomen chiefly, but is located more 
in the peripheral parts when the lumen of the large intes- 
tine is closed. 

The medical measures to be adopted in cases of occlu- 
sion of the intestine are purgatives, rectal injections, either 
liquid or gaseous, and the external application of electric- 
ity. Morphine, given for the relief of pain, is sometimes 
useful also as a direct remedy for the occlusion. Massage 
is very dangerous in these conditions. Capillary puncture 
of the intestine distended with gas is easy of accomplish- 
ment, but it can hardly serve as anything more than a 
palliative measure to be employed when the tympanism is 
extreme. 

The purgatives used should not be too energetic in their 
action. Extreme catharsis often does more harm than 
good, as it causes severe pain, vomiting, predisposes to 
peritoneal inflammation, and may even cause a sudden 
rupture of the intestine. Castor oil is the laxative of 
choice in this condition ; it is particularly indicated when 
there is reason to believe that the obstruction is due to fsecal 
accumulations in the csecum or colon, in the aged espe- 
cially. It may be given in one large dose of five to eight 
drachms in black coffee, or in teaspoonful doses repeated 
until the desired effect is produced. The oil may thus be 
given when the symptoms of obstruction are not very in- 
tense and when there is no vomiting. The saline purga- 
tives may also be employed, but they are inferior to castor 
oil. Under no pretext should the physician resort to the 



262 DISEASES OF THE STOMACH AND INTESTINE. 

use of drastic purgatives, even in small dose. If castor 
oil has proved ineffectual or if vomiting is so profuse that 
the oil will not be retained, we must resort to purgative 
enemeta or to high rectal injections. About an ounce of 
sulphate of soda may be added to the injection to produce 
a more intense action or we may use a decoction of two 
to five drachms of senna leaves with the addition of five 
or six drachms of sulphate of soda. Enteroclysis may be 
performed in the way which we have described above ; as 
large an amount as possible of liquid is to be injected, but 
extreme gentleness should be observed. For this reason 
we should avoid all effervescent mixtures and gaseous in- 
sufflations, which if they are not energetic are inefficacious, 
and if they are made with force ma}' be dangerous. A 
good result has often been obtained by the injection of 
seltzer water, the nozzle of a siphon being connected with 
a rubber tube attached to a rectal sound. Care should be 
taken to make the injection slowly and very gently. 

In a general way we are opposed to external manipula- 
tions; we may make cold applications, especially ice-bags, 
but this is a very secondary measure from which we can- 
not expect much in the way of results. 

After having tried castor oil and rectal injections we 
may resort to electricity, which lias sometimes produced 
good results; it may be given in the form of an electrical 
enema, which Boudet describes as follows : a galvanic cur- 
rent is employed and is applied by means of a special elec- 
trode consisting of a rubber sound inclosing a metallic 
stylet which does not reach quite to the extremity of the 
tube, so that it never comes in direct contaet with the mu- 
cous membrane. The negative current is made to pass 
through this stylet while the positive electrode is applied 
to the abdomen. The strength of the current should not 
exceed 10 to 15 milliamperes, and each seance should last 
about twenty minutes, care being taken to interrupt the 
current from time to time. The current passing through 
the stylet reaches the rectum through the liquid which has 
been previously injected. The positive electrode consists 



INTESTINAL OCCLUSION. 263 

of a cake of clay or of a metallic plate covered with chamois 
moistened with salt water, and is applied to the lumbar or 
epigastric region. Induced currents have sometimes been 
used, but they are certainly less serviceable than the con- 
tinuous current. This electrical enema is the best medical 
measure for overcoming intestinal occlusion ; it is often suc- 
cessful, and it possesses the advantages of at least being 
harmless, rapid in its action, not exhausting to the patient 
and not endangering the intestine. Even if a successful 
result is not obtained, the patient is still in good condition 
for surgical intervention. 

We cannot repeat too often that the medical attendant 
should take care not to use too violent means for overcom- 
ing the occlusion. We have several times seen patients 
who had taken large quantities of purgatives and numer- 
ous injections, and who were suffering from incessant 
vomiting, atrocious pain, and marked tympanites, recover 
without operation as a result of absolute rest, a few injec- 
tions of morphine, and applications of ice to the abdomen. 

It is true that morphine will not cure every case of in- 
testinal occlusion, but it is not improbable that in certain 
cases there are excessive antiperistaltic movements which 
interfere with the normal progression of the intestinal con- 
tent and cause stercoraceous vomiting, and even after the 
cause of the occlusion had been removed these symptoms 
might persist as a result of the antiperistalsis which mor- 
phine would subdue. We may, then, always give one or 
two injections of morphine if the vomiting and pain per- 
sist after the administration of purgatives and enemas. In 
any event this will give the patient a moment of relief and 
may even lead to recovery. It will allow us to employ, 
with the greatest chances of success, electrical enemata, 
and, if this fails, to resort to laparatomy, the ultima ratio 
of modern therapeutics. 

In case of excessive vomiting and of threatening exhaus- 
tion, we may employ hypodermic injections of artificial 
serum, to which we may add some phosphate of soda by 
reason of the tonic properties and of the stimulating action 



/ 



264 DISEASES OF THE STOMACH AND INTESTINE. 

upon the nervous system which have been attributed to 
hypodermic injections of this salt (Crocq fils, Huchard). 

It is well to remember also that lavage of the stomach 
has often given good results in intestinal occlusion ; it at 
least insures a short period of precious repose. Its good 
effects are probably due to the removal of toxines which 
have accumulated in the stomach. 



CHAPTER VIII. 
CANCER OF THE INTESTINE. 

The treatment of cancer of the intestine is wholly pallia- 
tive, nevertheless medical treatment may render valuable 
service in many cases. The physician may overcome the 
pain and may, by measures of hygiene and of intestinal 
antisepsis, prolong the patient's life. 

A milk diet answers the best in cases of intestinal car- 
cinoma, but it may be modified by the addition of eggs, 
purees, and occasionally of minced meat and food powders. 
Generally speaking, we should give food containing little 
indigestible matter, which is not liable to undergo fer- 
mentation and putrefaction. 

We may prevent stagnation of the intestinal contents by 
means of castor oil or saline purgatives. This obstruction 
is often favored by stenosis of the intestine, which may 
even end in complete occlusion. When the lesion is situ- 
ated in the lower portion of the large intestine we may 
occasionally re-establish the passage by catheterization by 
means of a rubber sound, or by enteroclysis. We should 
never forget that the utmost gentleness should be employed 
in these manoeuvres. 

Intestinal antisepsis will also be useful, as it reduces in 
a measure the evil results of auto-intoxication ; benzonaph- 
thol is the antiseptic to be preferred. In favorable cases, 
when the lesion involves the colon, which is its most fre- 
quent seat, antiseptic lavage of the large intestine may be 
done with advantage. 

The pain should be combated by hot poultices, opiates 
by enema, or hypodermic injections of morphine. 

Surgical intervention is to be thought of only in the 
earliest stages, at a time, unfortunately, when the diagno- 

265 



26G DISEASES OF THE STOMACH AND INTESTINE. 

sis is seldom certain. Later we can do no more than re- 
establish the flow of the intestinal contents and thus prevent 
occlusion from putting a comparatively early termination 
to the disease. It might be possible, in certain cases, to 
perform an intestinal anastomosis around the lesion, but, 
as a rule, in cancer of the lower part of the colon we must 
content ourselves with the establishment of an artificial 
anus. 



CHAPTER IX. 

INTESTINAL PARASITES. 

We shall consider in this chapter the treatment of tape- 
worm, ankylostoma duodenale, lumbricoids, and thread- 
worms. 

Taenia. — The most common varieties are taenia solium, 
taenia medio-canellata, and the bothriocephalus. The other 
varieties of tape-worm are seldom met with, at least in 
northern regions. The treatment is the same, whatever 
kind we have to deal with. The medio-canellata is be- 
coming more frequent than the solium ; the bothriocepha- 
lus is rather common in countries where large quantities 
of fish, especially salmon, are consumed, such as Switzer- 
land, northern Italy, and Sweden. The frequency of other 
forms of tape- worm is in relation especially with the con- 
sumption of raw or insufficiently cooked beef. As a meas- 
ure of prophylaxis we should always eat beef well cooked, 
and when it is desired to give raw meat as a therapeutic 
agent we should make use of mutton or horse-flesh. These 
animals are believed to be exempt from invasions of taenia. 

There are a certain number of general principles which 
should always be borne in mind in the treatment of tape- 
worm. In the first place we ought never to prescribe a 
taeniafuge medication until we are certain that the worm 
is sufficiently developed to make its entire expulsion, head 
and all, possible. Physicians are often pestered by noso- 
maniacs who believe they have a tape-worm and want to 
receive treatment with a view to its expulsion. Others 
really have a taenia and have received regular treatment 
for it ; but either the head has been expelled and the pa- 
tient simply imagines that the parasite is still present in 
his bowel, or the head remains but it is not yet time for 

267 



2G8 DISEASES OF THE STOMACH AND INTESTINE. 

the recommencement of measures looking to the destruc- 
tion of the worm. A physician should never prescribe for 
tape- worm unless he has seen some of the segments. He 
should never commence another course of tseniafuge treat- 
ment until the segments of taenia medio-canellata J appear 
again in the stools or until three or four months have 
elapsed since the expulsion of a solium minus its head. 

Another principle is to avoid too severe a fast as a pre- 
paratory measure. It was formerly the custom to subject 
the patient to absolute abstention from food, or at most to 
allow him a little milk, the day before the tseniafuge was 
to be taken. There is a danger in pushing this too far, 
for the condition of emptiness would favor the absorption 
of the poisonous substances contained in the remedies 
given. 

The expulsion of a tape-worm is accomplished in two 
stages : first, the administration of the medicinal substance 
destined to render the parasite torpid, to make it incapable 
of clinging to the intestinal wall ; and secondly, the admin- 
istration of a purgative in order to effect the expulsion of 
the benumbed worm. Too long a period ought not to be 
allowed to elapse between the administration of the tsenia- 
fuge and that of the purgative. 

As it is very necessary to know whether the head has 
been expelled or not, the patient should go to stool on a 
vessel filled with tepid water. The head appears as a 
slight swelling at the end of the very slender portion which 
forms the neck. The search for it, which is a very deli- 
cate matter, is much facilitated by this precaution ; fur- 
thermore, the worm is held suspended in the water and 
does not break. 

Of the remedies which are most efficacious for the ex- 
pulsion of a tape-worm we shall study male fern, pome- 
granate bark and the alkaloids derived from it, kousso, 

'Clinically the presence of taenia medio-canellata is recognized 
by the fact that the segments are passed spontaneously in small 
quantities. The patients find these segments almost daily in their 
stools, or even, when defecation has not taken place, in their clothes. 



INTESTINAL PARASITES. 269 

Corsican moss, and pumpkin seeds ; in this list we have 
ranged the substances according to their therapeutic value, 
except that for the first place there might be a contention 
between male fern and pomegranate bark or rather the 
salts of pelletierine discovered by Tanret. The latter are 
preferred by Berenger-Feraud * and Dujardin-Beaumetz. 
Their toxic action is, however, so marked and the results 
obtained by the ethereal extract of male fern, when ad- 
ministered according to Crequy's formula, are so favor- 
able that we prefer male fern to pomegranate. Kousso 
(bray era) has been practically given up on account of its 
very disagreeable taste, and it is, moreover, much less active 
than the first two named. Corsican moss and pumpkin 
seeds are hardly suitable except for children ; they have 
the very great advantage of being non-poisonous. 

Male Fern. — The fresh rhizome is used. The simple 
powder may be employed; this formed the basis of the 
formula sold by Mme. Muffler to Louis XVI: "Six 
grammes of powder of male fern in 125 to 180 grammes 
of water, to be taken at one dose in the morning fasting ; 
about an hour afterward a purgative, such as calomel and 
pulverized scammony, each 0.60 gramme, and gamboge, 
0.30" (Soulier). Paschier, of Geneva, was the first to 
make an ethereal extract of male fern ; he made pills of it 
mixed with calomel, but the powders prescribed by Crequy 
are to be preferred. These consist each of f grain of calo- 
mel and 7-J grains of the ethereal extract of male fern. The 
following is Crequy's mode of administration : 

1. The evening before, the patient takes no food but 
milk. 2. In the morning before breakfast from twelve to 
sixteen of the above powders inclosed in capsules are taken 
at intervals of five minutes. 3. If the expulsion of the 
worm has not been effected at the end of two or three hours, 
the patient takes from 2 to 3 ounces of syrup of ether, and 
after that from 1| to 2 ounces of castor oil. This method, 
which gives excellent results, is the one we prefer. It is, 
however, rather fatiguing and should not be employed 
1 "Legons Cliniques sur les Tsenias de l'Homme," Paris, 1888. 



270 DISEASES OF THE STOMACH AND INTESTINE. 

uselessly. We have s'een some patients, doubtless already 
predisposed, become markedly neurasthenic after having 
followed the treatment here described. It is well to know 
also that the ethereal extract of male fern possesses poison- 
ous properties, due, some believe, to the presence of filicic 
acid. The dose of %i to 5 drachms of the extract ought 
never to be exceeded. 1 As filicic acid is soluble in oil, 
we should not employ castor oil as a purgative in combina- 
tion with the male fern treatment. 

The bark of pomegranate root has often been employed 
in decoction, and this is not a bad preparation. It is made 
in the proportion of 2 ounces of the fresh bark of pome- 
granate root to 24 ounces of water. The bark is broken 
into small pieces, boiling water is poured over it, and it is 
left to macerate for twenty-four hours; it is then reduced 
by evaporation to 1(5 ounces and filtered. 

Soulier adds %i ounces of the contused bark to a glass- 
ful of boiling water; this is evaporated one-half over a 
slow fire and filtered ; another glassful of boiling water is 
added to the bark remaining in the filter, evaporated down 
one-half, filtered, and added to that previously obtained. 

Tanret has extracted four alkaloids from pomegranate 
bark, which he calls pelletierine «, /9, y, 8. Berenger-Feraud 
has shown that the last named two have no tseniafuge 
properties. The two other alkaloids may be employed 
alone or in combination. The following is the method 
which Dujardin-Beaumetz emplo} T s in the administration 
of these alkaloids: 2 the evening previous the patient is 
given a copious enema, and takes nothing in the way of 
food except milk ; in the morning while fasting he takes 
4| grains of sulphate of pelletierine in a solution contain- 
ing 7£ grains of tannin, ten minutes later a large glass of 
water, and then at the end of three-quarters of an hour 1 
ounce of compound tincture of jalap, 3 or better from 8 to 

] Lepine: "Semaine Medicale," p. 237, 1891. 

2 De Rochemure : These de Paris, 1879. 

3 Compound tincture of jalap (eau-de-vie allemande) is composed 
of jalap, 80 parts ; turpeth root, 10 ; scammony 20, and 60-per-cent 



INTESTINAL PARASITES. 271 

12 drachms of castor oil; the patient should be instructed 
to pass his stools in a vessel of tepid water. Berenger- 
Feraud prefers infusion of senna as a purgative. But 
whatever the drug employed as a purge it should be given 
three-quarters of an hour after the pelletierine. 

Kousso (brayera) is the female inflorescence of an Abys- 
sinian, tree of the order of rosacea. The powder of the 
flowers is given in doses of i to 1 ounce added to boiling 
water ; the water is allowed to cool and the whole is taken 
without straining. This infusion has a bad taste and often 
excites vomiting, which hinders the success of the treat- 
ment, Berenger-Feraud having had only twelve successful 
cases out of one hundred in which the remedy was used. 

Pumpkin seeds have given only five per cent of suc- 
cessful cases in the practice of the author just mentioned, 
but for all this the remedy is often useful in the case of 
children and should not, therefore, be wholly abandoned. 
To adults 2 ounces of the hulled and pounded seeds may 
be given mixed with an equal quantity of sugar or jam. 
An ounce of castor oil is to be taken one hour afterward. 
It has been recommended that a handful of the cleaned 
and pounded seeds be eaten with sugar every day for a 
week, at the end of which time a dose of castor oil is taken. 
A. Dumas 2 reports the case of a patient who passed a 
tape-worm, that had been rebellious to all treatment, after 
having taken such a mixture every morning for two 
months. 

Corsican moss is a mixture of various marine plants ; it 
is given in doses of 1 to 5 drachms in boiling milk. It is 
also employed as a vermifuge ; the following is suitable for 
a child two years old (Bouchardat) : steep 75 grains of 
Corsican moss in 3 ounces of boiling milk, strain and add 

alcohol, 960 parts. The dose here given of 1 ounce (30 grammes) 
is greater than we should venture to advise. Dujardin-Beaumetz, 
however, thinks that the action of the tannin and of the pelletierine 
tends to diminish that of the compound tincture of jalap so that 
there will be no undue purgation from this dose. 
1 Journal de Therapeutique, 1877. 



272 DISEASES OF THE STOMACH AND INTESTINE. 

5 drachms of sugar. This is to be taken in the morning 
fasting. 

Ascarides Lumbricoides. — The principal vermifuge for 
these parasites is Levant worm-seed and its active princi- 
ple santonin. The dose of Levant worm-seed is 15 to 90 
grains in honey, jam, or wafers. The dose of santonin is 
1 to 3 grains. We must not forget that the latter is a toxic 
substance which has been known to produce eclampsia in 
an infant of five months when given in a dose of less than 
half a grain (Binz). We must not forget also that it has 
a cumulative effect, and as we desire to avoid its absorp- 
tion the patient should not be fasting too strictly when it 
is taken. Its administration should be followed by a dose 
of some purgative, preferably castor oil. 

Oxyares Vermiculares. — These little worms inhabit 
exclusively the lower portion of the rectum and the anus, 
though occasionally in young girls they are found in the 
vagina. Vermifuge remedies taken by the mouth have 
no sort of effect upon them, and consequently we must 
treat them exclusively by local measures. One of the most 
simple methods of treatment consists in the use of cold- 
water enemata repeated several times a day ; a boric acid 
solution may also be employed in the same way. Dujardin- 
Beaumetz praises highly injections of equal parts of gly- 
cerin and water. In the case of young children who 
sometimes resist the giving of an enema we may insert 
little suppositories of mercurial ointment or a few threads 
of cotton or linen impregnated with the same substance. 

Ankylostoma Duodenale. — This parasite, discovered 
by Dubini, is very common in upper Italy and in Egypt. 
The famous epidemic of ansemia occurring among the 
workmen on the St. Gothard tunnel was attributed to the 
presence of this worm. It is about half an inch in length, 
and inhabits the duodenum, where it attaches itself to the 
mucous membrane and sucks the blood, thereby provoking 
numerous little hemorrhages which lead finally to an ex- 
treme degree of anaemia. It lives in the water of pools 
drunk by navvies and brick-makers ; and these workmen 



INTESTINAL PARASITES. 273 

should therefore be counselled to drink only boiled or fil- 
tered water and to wash their hands most carefully before 
eating. The ethereal extract of male fern is said to be the 
best anthelmintic remedy for this formidable parasite. 

Besides these parasites a number of protozoa are found,, 
the role of which in the production of intestinal disease is 
as yet unknown. Attention has hitherto been directed al- 
together to a study of the bacilli in the bowel, but it would 
be well to devote investigations to these protozoa, which 
may in certain cases have a most important pathogenic 
influence. 

18 



APPENDIX. 



Hyperchlorhydria and Round Ulcer. 

1$ Bicarbonate of soda, 3 iij. 

Prepared chalk, . 3 i. 

M. bene et ft. chart, no. xx. Sig. 15 or 20 powders a day. (De- 
bove. ) In case of constipation the prepared chalk may be replaced 
by magnesia. 

R Calcined magnesia, 

Prepared chalk, . . . . ' aa 3 i. 

Bicarbonate of soda, 3 v. 

M. et ft. chart, no. xx. Sig. One powder every half -hour for three 
hours following a meal. (Debove.) 

This powder is equal in its antacid effect to 38 grains of bicarbon- 
ate of soda. Calcined magnesia has a saturating action equal to four 
times its weight of bicarbonate of soda, and ammonio-magnesian 
phosphate to twice its weight of this salt. 



Stimulating Medication. 

R Tincture of ipecac, 

Tincture of calumba, 

Tincture of gentian, aa § ss. 

M. Sig. 20 to 30 drops, repeated in one-half to one hour, after 
eating. (A. Mathieu.) 

R Tincture of ipecac, 

Tincture of gentian, 

Tincture of nux vomica, . . . . aa | ss. 

M. Sig. 10 or 15 drops, repeated in an hour, after eating. (A. 
Mathieu. ) 

1 We reproduce here most of the formulae given in the text, add- 
ing some which have been recently proposed, without, however, 
guaranteeing their efficacy. 

275 





gtt. XV. 




gtt. XXX 




«▼. 


1 Barie I 






gtt. XXV 




gtt. xl. 



276 APPENDIX. 

]$ Sulphate of strychnine, gr. i. 

Distilled water, 3 vi - 

M. Sig. A teaspoonf ul with each of the three meals. (Grasset.) 

Vigier's mixture : 

1^ Bitter drops of Baume, ] mxlv. 

Tincture of bitter orange-peel, 

Tincture of star-anise, aa 3 iss. 

Tincture of calumba, 

Tincture of cinchona, aa 3 iiss. 

Peppermint water, . . . . • • . 3 ss. 

Orange-flower water, . . . • • • 3 i- 

Distilled water 3 vi J- 

M. et filtra. Sig. 1 or 2 tablespoonfuls before eatiug. 

1} Hydrochloric acid, .... 
Fluid extract of condurango, . 
Syrup of bitter orange-peel, 

M. Sig. A tablespoonful after each meal. 

^ Chloroform, 

Tincture of bitter orange-peel, 

Tincture of gentian. 

Tincture of star-anise, 

Tincture of nux vomica, . aa 3 i. 

M. et filtra. Sig. 10 or 20 drops in water fifteen minutes before 
each meal. (Huchard. ) 

3TRIC Atony with Constipation. 

^ Tincture of nux vomica. 

Tincture of gentian, aa, 3 ss. 

Tincture of orange peel 3 iiss. 

Fluid extract of cascara sagrada, .... Iiss. 

Syrup of orange-peel, 1 i J- 

M. Sig. A teaspoonful before each meal. (Barie.) 

1$ Tincture of nux vomica, 3 i- 

Tincture of rhubarb, 3 iss. 

Tincture of gentian. 

Tincture of calumba, 

Tincture of cinchona, aa 3 uss. 

M. et filtra. Sig. 15 to 20 drops before the two principal meals. 

1 One part of soot. 5 parts of carbonate of potash, and 500 parts of 
grated St. Ignatius bean are macerated for ten days in a closed vessel 
in 1,000 parts of alcohol ; the mixture is then expressed and filtered. 



APPENDIX. 



277 



Acid Medication. 

1$ Pure fuming hydrochloric acid, . . . . 3 i. 

Distilled water, . Oij. 

M. Sig. 1 or more wineglassfuls in divided doses after eating. 
(Bouchard.) 

1$ Hydrochloric acid, . 3 ss. 

Distilled water, § vi. 

M. Sig. A tablespoonful in a quarter of a glass of sweetened 
water two or three times a day after eating. (Hayem.) 

1$ Old " Rabelized" sulpho-nitric acid, 1 . . . 3 x. 

Distilled water, Oi. 

M. Sig. 1 or 2 tablespoonf uls after eating. (Coutaret. ) 



]$ Dextrin, 

Rum, 

Simple syrup, 

Water, 
M. et ft. elixir. 



Pepsinogenous Medication. 



(Dujardin-Beaumetz 



3ij- 
3iv. 
3 xiv. 



Gastro- Intestinal Antisepsis. 
Solutions for lavage of the stomach : 



Borax, 
Creolin, 
Salicylic acid, 
Thymol, 



3 iiss. : Oi. 
gr. iv.-viij 
gr. xviij. : 



Oi 



Oi. 



gr. iv. : Oi. 

— (Rosenheim.) 



1 The following is the formula for this acide sulfonitrique rabelise 

. 28 parts. 



I? Chemically pure sulphuric acid, 
Nitric acid, 
Alcohol 



180 



The acids are added very slowly to the alcohol in a vessel sur- 
rounded by ice, and the mixture is left in an unstoppered flask for 
two weeks ; then the flask is closed and the preparation is allowed 
to ripen for ten months before being used. It contains sulphonitric 
acid and a small quantity of nitric ether. 



278 



APPENDIX. 



. 3 iv. 
. 3ij. 
From 3 to 12 powders in the 



aa 3 uss. 
powder at each of the prin- 



3 Beta-naphthol, .... 

Salicylate of bismuth, 
M. et div. in chart, no. xxx. Sig. 
twenty-four hours. (Bouchard.) 

Benzonaphthol may be given in powders of 7^ grains each, re 
peated eight or ten times a day. 

1^ Salicylate of bismuth, 

Henry's magnesia, 

Bicarbonate of soda, 
M. et div. in chart, no. xxx. Sig. 
cipal meals. (Dujardin-Beaumetz.) 

1$ Beta-riaphthol, 

Salicylate of bismuth, 

Bicarbonate of soda, . 
M. et div. in chart, no. xxx. Sig. 
pal meals. (Dujardin-Beaumetz.) 

3 Salol, 

Salicylate of bismuth, 
M. et div. in chart, no. xxx. Sig. 
cipal meals. (Dujardin-Beaumetz.) 

1} Salicylate of bismuth, 

Alpha-naphthol, 

Charcoal, 

M. et div. in chart, no. xxx. Sig. 
cipal meals. 

1^ Salicylate of bismuth, 

Alpha-naphthol, 

Prepared chalk, 

Phosphate of lime, 
M. et div. in chart, no. xl. Sig. 1 
cipal meals. 

H Lactic acid, .... 

Water, 

Simple syrup, ........ 3 xxv. 

M. Lactic acid lemonade. (Hay em.) 

Antidiarrhceic lemonade particularly recommended in choleraic 
diarrhoea and cholera : 

1^ Pure hydrochloric acid, 3 ss. 

Resorcin, 3 ss. 

Syrup of orange-peel, 3 v. 

Water, q.s. ad % vi. 

M. Sig. A tablespoonful every two to four hours. (Menche.) 



aa 3 uss. 
1 powder at each of the princi- 



aa 3 ss. 
1 powder at each of the prin- 



aa 3 uss. 
1 powder at each of the prin- 



aa 3 iiss. 
powder at each of the prin- 

. 3 iiss.-iv. 
• 5vij. 



APPENDIX. 279 

For dyspepsia with diarrhoea : 

]} Vinegar of opium, 

Bitter drops of Beaume, * . . . aa 3 i. 

M. Sig. 4 drops before each meal. (Grasset. ) 



Treatment of Pain. 
Gallard's White Drops : 

]$ Hydrochlorate of morphine, gr. iss. 

Cherry -laurel water, ntlxxv. 

M. Sig. 1 or 2 drops on a lump of sugar at the beginning of 
the meal. 

I£ Extract of belladonna, 

Powdered belladonna leaves, . . . aa gr. iss. 

M. et ft. pil. no. x. (Trousseau.) 

Ty Hydrochlorate of cocaine, gr. iss. 

Distilled water, . 1 x. 

M. Sig. To be taken in tablespoonful doses in the course of two 
days. 

3$ Extract of cannabis indica, gr. £—£. 

Alcohol, q.s. 

"Water, I v. 

M. Sig. To be taken in four or five doses during the twenty-four 
hours. 

1$ Menthol, gr. iss.-ij. 

Alcohol, q.s. 

Distilled water, . . . . . . . % vi. 

M. Sig. To be taken in tablespoonful doses. (Bardet. ) 

]$ Menthol, . gr. xv. 

Alcohol, . 3 v. 

Simple syrup, § i. 

M. Sig. A tablespoonful every hour. . 

1$ Saturated chloroform water, 3 v. 

Linden -flower water, 1 iij- 

Simple syrup, 3 x. 

M. Sig. To be taken in tablespoonful doses. 

I£ Nitrate of silver, gr. iij.-v. 

Distilled water, 1 iij. 

M. Sig. 2 teaspoonfuls three times a day. For gastric hyper- 
sesthesia. (Rosenheim. ) 

1 See foot-note to Vigier's mixture on page 276. 



280 



APPENDIX. 



1$ Powdered opium, gr. vi. 

Prepared chalk, 

Bicarbonate of soda, aa 3 iiss. 

M. et div. in chart, no. xx. Sig. 2 or 3 powders at the begin- 
ning of a meal. 

^ Powdered opium, gr. vi. 

Magnesia, 

Bicarbonate of soda, aa 3 iiss. 

M. et div. in chart, no. xx. Sig. 2 or 3 powders at the begin- 
ning of a meal. 

Either of the above may be used to combat a slight hyperacidity 
combined with hyperesthesia of the gastric mucous membrane. 



Chlorodyne (Remington's formula) 

1$ Hydrochlorate of morphine, 

Water 

M. et adde — 

Oil of peppermint. 

Dilute hydrocyanic acid, . 

Tincture of capsicum, 

Hydrochloric acid, 

Tincture of cannabis indica, 

Chloroform, 

Water, .... 
M. Six minims contain yV grain of morphine. 



gr. xvi. 
3i- 

Tliv. 

Tt[xxiv. 

mxviij. 

3 ss. 

3ij- 

3iij- 

Si. 



Laxatives and Purgatives. 
Lutz's pills : 

1$ Resin of aloes, 

Resin of jalap, 

Resin of scammony, . 

Aqueous solution of caustic soda (29 per cent) , 

Glycerin, 

M. et ft. pil. no. xx. Sig. 1 pill at bedtime. 

1$ Extract of belladonna, 

Powdered belladonna leaves, . 

Podophyllum, 

Extract of liquorice, .... 

M. et ft. pil. no. xii. Sig. 1 or 2 pills at night. 



3 Extract of belladonna, 

Podophyllin, 

M. et ft. pil. no. xx. Sig. From 1 to 3 pills at bedtime. 



aagr. xv. 

. TT1.XV. 

• TUviij. 



aagr. ij. 
. gr. iv.-vi. 
. q.s. 

• gr. iij. 
. gr. viij. 



APPENDIX. 281 

3 Podophyllin, gr. ivss. 

Powdered ginger, gr. iij. 

Honey, q.s. 

M. et ft. pil. no. x. Sig. 1 or 2 pills at night. (C. Paul.) 

Purgative draught of the Hopital Saint-Louis : 

I£ Senna leaves, 

Viola tricolor, aa 3 ij. 

M. Infuse for one hour in two pints of boiling water, strain, and 
sweeten with honey. Dose : a large glassful in the morning. 
(Hardy.) 

Compound liquorice powder : 

1$ Powdered senna leaves, 

Sublimed sulphur, aa 3 iss. 

Powdered star-anise, 
Powdered fennel, 

Cream of tartar, aa gr. xlv. 

Powdered liquorice, 3 ij. 

Sugar, 3 vi. 

M. et ft. pulv. Sig. From a teaspoonful to a tablespoonful at 
bedtime. 

I£ Magnesia, 

Cream of tartar, 

Precipitated sulphur, aa § ss. 

M. et ft. pulv. Sig. A teaspoonful in a quarter of a glass of 
water once or twice a day at meal-time. 

For gastro- intestinal atony with constipation : 

1$ Magnesia, 

Precipitated sulphur, 

Cream of tartar, 

Powdered liquorice, aa 3 v. 

Powdered ipecac, gr. ivss. 

M. et ft. pulv. Sig. A teaspoonful in a quarter of a glass of 
water once or twice a day at meal-time. 

Purgative coffee : 

1$ Senna, 3 iiss. 

Sulphate of magnesia, 

Roasted and ground coffee, . • . . aa § ss. 
M. Sig. Infuse in four ounces of boiling water, strain, and 
sweeten ; sufficient for one dose. 



282 

Purgative species : 



APPENDIX. 



1$ Senna leaves, 

Sambucus flowers, 

Green anise leaves, . 
' Fennel, 

Bitartrate of potash. 
M. Sig. To make one cup of infusion. 



. gr. xxx. 
aagr. xv. 
aagr. viij. 



Castor oil : 




1$ Castor oil. 


? i 


Gum arabic 


• 3ij. 


Peppermint water, .... 


. 3 ix. 


Simple syrup, ..... 


. : iiss 


Water, ...... 


• lu- 


M. 





This preparation of the French Codex is often rejected 
vomiting. 



1$ Saccharate of casein, 

Castor oil, 

Water, 

M. ft. emulsio el adde : 

Cherry-laurel water, 

Water 

M. Castor-oil emulsion. (Leger.) 



3 i- 
3 iij 



1^ Castor oil, 

Orgeat (syrup of almonds) , 
Syrup of acacia, 
Peppermint water, . 
Distilled water, 



ad 



by 



3 uss. 
q.s. aa § v. 

Pour the syrup in a bottle and shake it so as moisten the sides ; then 
pour in the oil and shake well for two <>r three minutes; add the 
peppermint water and distilled water. The liquid has the appear- 
ance of a white linctus. 



Citrate of magnesia lemonade : 




1$ Citric acid, 


• • Si- 


Carbonate of magnesia, 


. 3 ivss 


Distilled water, .... 


. • §x. 


Simple syrup, 


. 1 iij- 


Tincture of lemon, .... 


. TltxV. 


M. 





APPENDIX. 283 

"Medecine Blanche" of the French Codex: 

1$ Calcined magnesia, . . . . • . 3 ij- 

White sugar, . § iss. 

Orange -flower water, 3 v. 

Water, 3 x. 

M. 

Nutrient Enemata. 

]$ Yolk of egg, no. i. 

Dry peptones, ...... 2 dessertspoonfuls. 

Laudanum, 5 drops. 

Bicarbonate of soda, . . . .8 grains. 

M. For one enema. To be repeated night and morning. (Dujar- 
din-Beaumetz.) 

B Milk, 

Beef tea, aa 3 ounces. 

Yolk of egg, no. i. 

Peptones, 1 teaspoonful. 

Rum, 1 ounce. 

M. 

Dysentery. 

1$ Powdered ipecac, 3 i. 

Boil for five minutes in 

Water, . §iij. 

Filter and add 

Syrup of opium, 1 

Cinnamon water, aa § i. 

M. Sig. Tablespoonful doses every hour. (Delioux de Salignac. ) 

Segond's Pills : 

I£ Powdered ipecac, gr. vi. 

Calomel, gr. iij. 

Extract of opium, gr. i. 

Syrup of buckthorn, q. s. 

M. et ft. pil. no. vi. 

Sublimate enema : 

3$ Corrosive sublimate, gr.ij.-iij. 

Water, Oi. 

Alcohol, q.s. 

M. Sig. For two injections, one in the morning and one in the 
evening. (Bonamy.) 



A solution of one grain of extract of opium in one ounce of syrup. 



284 APPENDIX. 

Enema for muco- membranous enteritis : 

1$ Subnitrate of bismuth. 

Salicylate of bismuth, . . . . aa 3 iiss. 

Mucilage of quince seeds, . . . . Oi. 

M. Sig. For rectal injection. (Revilliod.) 

Intestinal Parasites. 
Tape- worm : 

1$ Ethereal extract of male fern, 3 iiss. 

Calomel, ......... gr. xv. 

M. et div. iu capsulas no. xx. Dose : 12 to 16 capsules. (Crequy.) 

]$ Fresh bark of pomegranate root, . . . . § i j . 

Water Oiss. 

Macerate for twenty -four hours, and then evaporate to one pint. 

1} Pounded bark of pomegranate root, . . . § iiss. 
Boiling water, 1 glassful. 

Evaporate to one-half over a gentle fire ; filter and pour another 
glass of boiling water on the residue ; evaporate again one-half on a 
slow fire, filter, and mix the two. (Soulier.) 



INDEX. 



Abdomex, inspection of, 2 

palpation of, 3 

support of, in neuro-motor 

dyspepsia, 95, 103, 125, 127 

Acid medication, prescriptions, 

277 
Acidity of urine, 26 
Alcohol, influence of, upon di- 
gestion, 57 

in dyspepsia, 58 
Ankylostoma duodenale, 272 

ethereal extract of male 
fern in treatment of, 293 
Antisepsis, g a s t r o-in testinal, 
207 

gastric, 210 

intestinal, 212 

of stomach in dilatation, 139 
Appendicitis, 254 

aim of operative interfer- 
ference, 257 

former treatment of, 255 

laparatomy in, 256 

parietal, 255 

perforative, 255 
Appendicular colic, 255, 256 

cause of, 256 

treatment of, 256 
Appetite, 

arsenic to improve, 160 

appetizers, 160 

bitters, 159 

bulimia, 159 

climatotherapy, 159 

diminished, 159 

disorders of, 159 



Appetite, 

hydrotherapy, 159 

orexine hydrochloride, 160 

massage, 159 

stomach tube, 160 

treatment of disorders of, 
159 
Ascarides lumbricoides, 272 

Levant worm seed in treat- 
ment of, 272 
Aspiration of stomach, 11 
Asthenic dyspepsia, 88 
Atonic dyspepsia, 88 

dilatation of stomach, 129 
Auto-intoxication, gastric and 
intestinal, 207, 214 

treatment of, 207 

milk diet in, 208 

vegetable diet in, 209 

dietary for, 209 

Beverages in dyspepsia, 57 

alcohol, 57 

beer, 59 

hot drinks, 60 

table waters, 59 

wine, 59 
Bile in faeces, 33 
Blood in faeces, 35 
Bouveret's treatment of hyper- 

chlorhydria, 84 
Bulimia, 159 

Cancer of intestine, 265 
castor oil in, 265 
intestinal antisepsis in, 265 



286 



INDEX. 



Cancer of intestine, milk diet 
in, 265 
saline purgatives in, 265 
surgical intervention in, 265 
treatment of pain in, 265 
Cancer of stomach, 243 
anorexia in, 244 
condurango in, 243 
in dilatation of stomach, 138 
diminution of hydrochloric 

acid in, 244 
gastroenterostomy in, 246 
gastrorrhagia in, 246 
mechanism of vomiting in, 

246 
milk diet in, 243 
opiates for pain of, 246 
pain in, 246 

rectal alimentation in, 245 
surgical treatment of, 246 
treatment of gastric fer- 
mentation in, 245 
Catarrhal gastritis, 89 
Cham A 'sclassifical ion of symp- 
toms of locomotor ataxia, 146 
Chemical dyspepsia, manage- 
ment of, in (1 i lata T ion, 140 
examination of contents of 

stomach, 13 
study of gastric digestion, 7 
Chlorides in urine, 28 
Cliniatotherapy, in disorders of 
appetite, iV.) 
in nervo-motor dyspepsia, 
95, Kio 
Colon, examination of, 6 
Minkowski's method, 7 
Simon's method. 7 
Von Zienissen's method, 6 
Constipation, 161 

absence of secretion of in- 
testinal juices due to, 161 
of alimentary origin, 161 
aloes in, 177 
Anderson's pills in, 177 
in the aged, 180 



Constipation, belladonna in, 175 

cascara in, 175 

castor oil in, 178 

causes of, 162, 163 

cause of dyspepsia, 162 

in children, 179 

complications of, 164, 181 

degrees and clinical forms 
of, 163 

diet for, 165, 166 

diminution of muscular 
contractility due to, 161 

in dilatation of stomach, 
141 

Dujardin-Beaumetz's clas- 
sification of, 161 

electricity in, 170 

in enteroptosis and obesity, 
180 

faulty hygiene, due to, 178 

in gastro-intestinal dyspep- 
sia, 179 

Germain SeVs powder in, 
174 

gymnastics in. 167 

hemorrhoids complicating, 
187 

hydrotherapy in, 167 

hygienic treatment of, 165 

injections in, 167 

laxatives in, 171 

laxative powder of Mat- 
thieu, 174 

Lntz's pill. 177 

magnesia in, 172 

manna in, 176 

massage in, 167 

muco-membranous enteri- 
tis complicating, 182 

pilule ante-cibum, 177 

podophyllin in, 194 

rectum, disordered sensi- 
bility of as cause, 161 

rhamnus frangula in, 175 

rhubarb in, 175 

scammony in, 177 



INDEX. 



287 



Constipation, senna in, 176 

suppositories in, 169 

tamarinds in, 175 

treatment of, 164 
Cures, 56 

grape, 56 

whey, 57 

Debove's tube, 9 

Detritus, alimentary, in faeces, 

32 
Diagnostic technique, 1 
Diarrhoea, 192 

acetate of lead in, 202 

astringents in, 199 

Bouchardat's substitute for 
diascordium in, 199 

bismuth subnitrate in, 200 

catechu in, 202 

definition of, 192 

diascordium in, 198 

diet in, 196 

etiology, 192 

inert powders in, 199 

morning, 205 

nervous, 204 

opium i and morphine in, 
198 

oxide of zinc in, 201 

peristaltic sedatives in, 198 

prepared chalk in, 201 

restoration of lost fluid to 
organisms in, 202 

rhatany in, 202 

talc in, 201 

tannin in, 201 

treatment of, 196 

uraemic, 204 

venous transfusion in, 203 
Diet in auto-intoxication, 208 

in constipation, 165, 166 

in dilatation of stomach, 138 

in dyspepsia, 39 

in dyspepsia, nervo-motor, 
95 

Gautier's table of, 38 



Diet, general considerations on, 
38 

in hyperehlorhydria, 81, 84 

milk, 208 

vegetable, 209 
Dietary for dyspepsia, Leube's, 
41 

vegetarian, of Dujardin- 
Beaumetz, 55 
Dilatation of stomach, 69 

antisepsis of stomach in, 139 

atonic, temporary or per- 
manent, 129 

cancer in, 138 

constipation in, 141 

diagnosis of, 132 

diet in, 136 

gastroenterostomy in, 139 

hydrochloric acid in, 140 

with hypersecretion, 129 

management of chemical 
dyspepsia in, 140 

mechanical, 129 

prognosis of, 134 

stasis with, 128 

surgical intervention in, 138 

symptoms of, 130 

treatment of, 136 
Diseases of stomach and intes- 
tine, classification of, 228 
Duodenum, ulcer of, 236 
Dujardin-Beaumetz's classifica- 
tion of varieties of constipa- 
tion, 161 
Dysentery, 251 

ailanthus glandulosain, 252 

antiseptic enemata in, 252 

astringent enemata in, 252 

calomel in, 252 

ipecac in, 252 

milk diet in, 253 

prescriptions, 283 

purgatives in, 251 
Dyspepsia, 221 

atonic, 88 

asthenic, 88 



288 



LN-DEX. 



Dyspepsia, divisions of, G2 
flatulent, 89 
nervo-niotor, 88 
nervous, 221 

relation with gastritis, 229 
treatment of. 62, 223 

Electricity in constipation, 
170 
in gastric crises, 153 
in nervo-niotor dyspepsia, 

95, 101 
in vomiting, 158 
Enemata, nutrient prescrip- 
tion- 
Enteralgia, 143 
Enteritis, 248 

location of seat of inflam- 
mation, 248 
Enteritis, acute. 249 
antisepsis in. 249 
bismuth subnitrate in. 248 
diet in, 249 
opium in. 249 
prepared chalk in. 249 
saliein purge in. 3 i ( .» 
treatment of. 249 
treatment of pain in, 249 
Enteritis, chronic, 21'.' 

chronic diarrhoea of mala- 
rial origin, 250 
chronic diarrhoea of warm 
countries, 250 
Enteritis, chronic ulcerative, 
250 
diarrhoea in, 250 
diet in, 250 

enemata and lavage in. 250 
nitrate of silver in, 250 
Enteroclysis, 213 
Enteroptosis. 124 
Ethyl-green in examination of 

gastric juice, 16 
Ewald's method of expression, 

12 
Ewald and Siewers' method for 



estimation of gastric motility, 
24 

Exci to-motor medication in 
nervo-motor dyspepsia, 104 

Excreta, study of, 24 

Expression of contents of stom- 
ach, 12 

External examination, 2 

Fat in the faeces, 31 

examination of, 31 
Fanchers tube. '.» 
F«ces, alimentary detritus in, 
32 

bile in, 33 

blood in, 35 

chemical examination of 
fat in. :)1 

fat in, ;;<> 

mucus in. '■)'.) 

pus in, :iii 

starch in, 32 

study of, 25. 30 
Fermentation of food outside 

of body, 207 
Food powders, 52 

of meat. 52 

of starchy foods. 54 
Fremont's tube, 9 

Gastralgia, 143, 155 
Gastric antisepsis, 210 

borax in, 212 

boric acid. 212, 219 

chlorate of potash, 212 

chlorate of soda, 212 

chloride of sodium, 212 

creolin, 212 

hydrochloric acid, 212 

hyposulphite of soda, 212 

lactic acid, 212, 219 

lavage, 219 

mechanical, 211 

permanganate of potash, 
212 

resorcin, 212 



INDEX. 



289 



Gastric antisepsis. 

salicylic acid, 212 

thymol, 212 

Vichy water, 212 
Gastric atony, with constipa- 
tion, prescriptions, 276 
Gastric crises, 142 

antipyrin in, 152 

baths in, 153 

belladonna in, 149 

bromides in, 153 

cannabis indica in, 151 

chlorodyne in, 151 

chloroform water in, 150 

cocaine in, 150 

condurango in, 152 

counter-irritation in, 154 

electricity in, 153 

ether in, 152 

hot applications in, 153 

of locomotor ataxia, Char- 
cot's classification, 146 

menthol in, 152 

morphine in, 148 

nitrate of silver in, 152 

opium in, 147 

solanine in, 151 

sulphide of carbon in, 150 

symptoms of, 145 
Gastric digestion, chemical 

study of, 7 
Gastric hyperaesthenia, 67 
Gastric and intestinal hemor- 
rhage, 226 
Gastric juice, examination of, 
7, 14 

acidity of, 14 

qualitative examination of, 
15 
Gastric motility, 23 

estimation of, 23 

Ewald and Siewers' method, 
24 

Klemperer's method for es- 
timation of, 23 

Leube's method, 24 
19 



Gastritis, acute, 229, 230 
alkalies in, 231 
hypodermoclysis in, 231 
ice in, 231 
milk diet in, 231 
morphine in, 231 
relations with dyspepsia, 

229 
toxic, 230 
treatment of, 231 
Gastritis, atrophic, 233 

cause of pernicious anaemia, 
233 
Gastritis, chronic, 232 
alkalies in, 233 
catarrhal, 89, 232 
with excessive secretion of 

hydrochloric acid, 233 
with hypersecretion of mu- 
cus, 232 
lavage in, 233 
Gastritis, ulcerative, 234 
Gastritis, with submucous hy- 
pertrophic sclerosis, 233 
Gastro-enterostomy in dilata- 
tion of stomach, 139 
as palliative measure in 
cancer of stomach, 246 
Gastro-intestinal antisepsis, 207, 
210 
antiseptics, 211, 220 
dietary, 209 
milk diet, 208 
mechanical, 211 
prescriptions, 277 
vegetable diet, 209 
Gastro-intestinal atony in hy- 

perchlorhydria, 86 
Gastro-intestinal diseases, treat- 
ment of, 62 
Gautier's diet table, 38 

method for determination 
of organic acids in gastric 
juice, 21 
Gavage, 12 

in diminished appetite, 160 



290 



IXDEX. 



Gavage in treatment of vomit- 
ing, 158 
Germain-See's powder in con- 
stipation, 174 
Gouttes aineres de Baume, 159 
Grape cure, 56 
Giinzberg's test in examination 

of gastric juice, 16 
Gymnastics, 

in constipation, 167 
in nervo-motor dyspepsia, 
100 

Haykm on nervo-motor dys- 
pepsia, 90 
Hayemand Winter's method of 

study of gastric juice, 7 
Hemorrhage, gastric and intes- 
tinal 236 
anemia resulting from, 227 
ergot in, 226 
ice-bag in, 226 
opium iu, 336 
perehloride of iron in, 226 
Rabel water in, 336 
rest in, 226 

transfusion after, 227 
treatment of, 226 
Hemorrhoids, 

hemorrhage from, 190 
pain, relief of. 190 
symptoms of, 187 
treatment of, 188 
Hydrotherapy, 

in constipation, 167 
in disorders of appetite, 159 
in nervo-motor dyspepsia, 
95, 101 
Hydrochloric acid in gastric 
juice, 66 
normal and a b no r in ;i 1 
amount. 07 
Hyperchlorhydria, 66 

antacid medication in, 76, 

79 
atropine in, 81 



Hyperchlorhydria, Bouveret's 
treatment of, 84 

Carlsbad water in, 81 

calcium salts in, 78 

causes of, direct, 72 

causes of, indirect, 73 

continuous, 68 

diagnosis of, 70 

diet in, 81, 84 

gastro-intestinal atony in, 
86 

nature of, 69 

nitrogenous food in, 82 

pains, treatment of, 87 

potassium salts in, 78 

prescriptions for, 275 

simple, (J? 

sodium salts in, 77 

treatment of, 71 

varieties of, 66 

vegetarian diet in, 82 

Vichy and Vals in, 80 
Hyperpepsia, 66 
Hypersecretion with hyper- 
chlorhydria and permanent 
stasis, 129 

Ixdicax in urine, 29 
Indigestion, acute, 221 

alkalies in, 334 

antiseptics in, 225 

chloroform water in, 224 

diet in. 224 

elimination of toxines in, 225 

hydrochloric acid in, 224 

lactic acid in, 224 

lavage in 224 

milk diet in, 224 

purgatives in, 224 

subacute, 222 

treatment, 223 
Indol in urine, 29 
Injections for constipation, 168 

with emollients, 168 
glycerin, 168 
honey, 168 



INDEX. 



291 



Injections for constipation, 

withmiel demercuriale, 168 
oil, 169 
sea salt, 168 
sulphate of soda, 169 
Inspection of abdomen, 2 
Internal examination of stom- 
ach, 7 
Intestine, cancer of, 265 

examination of, 6 

and stomach, diseases of, 228 
Intestinal antisepsis, 212 

ascending douches, 212 

benzonaphthol, 218 

beta-naphthol, 215, 217 

betol, 216 

bismuth salicylate, 215, 216 

black sulphide of mercury, 
216 

calomel, 212 

charcoal, 217 

eucalyptol, 216 

lavage, 212 

magnesia salicylate, 216 

naphthalin, 216 

purgatives, 212 

resorcin, 218 

salol, 216 
Intestinal crises of locomotor 

ataxia, 147 
Intestinal occlusion, 259 

capillary puncture in, 261 

castor oil in, 261 

causes, 259 

causes external to intestine, 
259 

diagnosis of, 260 

electricity in, 261, 262 

enteroclysis in, 2(52 

hyperodermic injections in, 
263 

invagination and intussus- 
ception as causes of, 259 

lavage of stomach in, 264 

massage in, 261 

morphine in, 261, 263 



Intestinal occlusion, obstruc- 
tion of lumen as causes, 
259 
occlusion by lesions of walls 

as causes, 259 
precautions in treatment of, 

260 
pseud o-strangulation as 

cause, 259 
purgatives in, 261 
purgative enemata in, 262 
rectal injections in, 261 
strangulation as cause, 259 
Intestinal pains, 155 
Intestinal parasites, 267 

ankylostoma duodenale,272 
ascarides lumbricoides, 272 
oxyures vermiculares, 272 
prescriptions for, 284 
tape worm, 267 

Klemperer's method for es- 
timation of gastric motility, 
23 

Kussmaul, tormina nervosa of, 
144 

Lavage of stomach, 12 

for vomiting, 158 
Laxatives, 171 

powder of Matthieu, 174 
prescriptions, 280 
Leube's dietary in dyspepsia, 41 
Leube-Rosenthal meat solu- 
tion, 41 
Leube's method for determina- 
tion of gastric motility, 24 

Massage in constipation, 167 
in disorders of appetite, 159 
in nervo-motor dyspepsia, 
95, 101 
Matthieu and Redmond's method 
of measuring amount of fluid 
in stomach, 15 



292 



INDEX. 



Meat in dietary for dyspeptics, 
44 

cooked, 45 

extracts, 46 

peptones, 46 

raw, 44 

solutions, 46 
Methyl-violet in examination 

of gastric juice, 16 
Mechanical dilatation of stom- 
ach, 12!) 

symptoms of, 130 
Milk in dietary lor dyspeptics, 
47 

condensed, 51 

koumyss, 51 

kephir, 52 

powders, 51 

quantity of, 47 

varieties of, 47 
Milk diet. 308 

sterilized, 209 
Movable kidney, 135 
Muco-membranous enteritis in 

constipation, 182 
Mucus in faces, 33 

Nervo-motob dyspepsia, 88 
acid medication in, 112 

alcohol in. mi*. 110 
alkalies in. 108 
bitters in, 105, 106 
bread in, 98 

causes of, 93 

change of scene in, 90 
chloride of sodium in, 109, 

110, 111 
climatotherapy in. 95, 100 
creosote in, 109 
digestive ferments, 116 
diet in, 95 
drinks in. 97 
electrization in. 95. 102 
enteroptosis as cause of, 124 
excito-motor medication in, 

104 



Nervo-motor dyspepsia, excito- 
secretory medication in, 
K>7 

gymnastics in, 100 

hydrochloric acid in, 112 

hydrotherapy in, 95, 101 

ice in, 98 

iodine in, 109 

iodides and bromides in, 109 

ipecac in, 105 

kephir in. 109, 111 

massage in, 95, 101 

mechanical support of ab- 
domen in, 95, 103 

milk in, 98 

movable kidney a cause of, 
1 35 

pancreatin in, 116 

pepsin in. no 

pepsinogenous substances 
in. 120 

Babelized su 1 pho-n itri e 
acid in, 1 1 5 

resume* of treatment of, 121 

salol in. 105 
severe tonus of. 122 

symptoms of. do 
sulphate of sodium in, 109, 
lio. HI 
Nitrogen, amount contained in 

excreta, 25 
Nutrient enemata, prescrip- 
tion-. -J--; 

Organic acids, determination 
of, 21 
Gautier's method, 21 
Oxyures verm icula its. 272 

enemata in treatment of. 272 
suppositories in treatment 
of. 272 

Paix, prescriptions, 279 
Pains symptomatic of dyspep- 
sia. 154 
intestinal, 155 



INDEX. 



293 



Painful phenomena in diseases 
of stomach and intestine, 
treatment of, 142 
Palpation of abdomen, 3 
Paracresol in urine, 29 
Parietal appendicitis, 256 

treatment of, 256 
Pepsinogenous medication, pre- 
scriptions, 277 
Percussion of stomach, 3 
Perforation of stomach, 241 
Perityphlitis, 254 
Phenol in urine, 29 
Phosphates in urine, 28 
Pilulse ante cibum for constipa- 
tion, 177 

Anderson's, 177 

Lutz's, 177 
Powders, food, 52 

meat, 52 

preparation of meat, 52 

starchy, 54 
Prescriptions, 275 

acid medication, 277 

dysentery, 283 

gastric atony with consti- 
pation, 276 

gastro-intestinal antisepsis, 
277 

hyperchlorhydria, 275 

intestinal parasites, 284 

laxatives, 280 

nutrient enemata, 283 

pain, 279 

pepsinogenous medication, 
277 

purgatives, 280 

round ulcer, 275 

stimulating medication, 275 
Purgatives, prescriptions, 280 
Pus in faeces, 36 
Pylorus, lesions of, causation 
of dilatation of stomach, 129 

Qualitative examination of 
gastric juice, 15 



Rabel water, 226 
Reichmann's disease, 68 
R6mond and Debove on nervo- 

motor dyspepsia, 90 
Reinondand Matthieu'smethod 

of measuring amount of fluid 

in stomach, 15 
Revalesciere, 54 
Riviere's potion, 157 
Round ulcer, prescriptions, 275 

Siewers and Ewald's method 
for determination of gastric 
motility, 24 
Simon's method of exploring 

colon, 7 
Simple ulcer and ulcerative gas- 
tritis, 234 
difference between, 234 
Starch in faeces, 32 
Starchy powders, 54 
Stomach, 

cancer of, 243 
dilatation of, 128 
and intestine, diseases of, 228 
inflammations of, 229 
lesion of walls of, 129 
percussion of, 3 
perforation of, 241 
succussion of, 4 
Stimulating medication, pre- 
scriptions, 295 
Succussion of stomach, 4 
digital, 4 
total, 4 

Hippocratic, 4, 5 
Sulphuretted hydrogen in 

urine, 28 
Sulpho-acids iii urine, 28 
Surgical intervention in dilata- 
tion of stomach, 138 

Tape-worm, 267 

Corsican moss in, 271 
general principles of treat- 
ment, 267 



294 



IXDEX. 



Tapeworm, kousso in, 271 

male fern in, 269 

pomegranate root in, 270 

pumpkin seeds in, 271 

sources of, 207 

varieties of, 267 
Technique, diagnostic, 1 
Tormina nervosa of Kussmaul, 

144 
Toxic substances in urine, 28 
Treatment of dyspepsia and 

gastro-intestinal disease, 62 
Tube, DeboveV. 9 

Faucher's, 9 

Fremont's, 9 

introduction of, 10 
Typhlitis, 254 

secondary, 257 

UffelmANN'S reagent in exam- 
ination of gastric juice, 16 
Ulcer of stomach, 234 

abstinence from food in, 236 
alkalies in, 239 
complications of, 241 
cicatricial narrowing of py- 
lorus with, 242 
difference between, and ul- 

cerat i ve gastritis, 334 
food powders in, 238 
hydrocyanic acid for vom- 
iting in, 241 
milk diet in, 236, 237 
nitrate of silver for vomit- 
ing in, 241 
pain in, 240 
peptic ulcer, 236 
perforation, 241 
rectal alimentation in, 237 
subcutaneous injections in, 

237 
symptoms of, 235 
tincture of iodine in, 241 



Ulcer of stomach, treatment of, 
236 

treatment of pain in, 240 

ulcer of duodenum, 236 

vomiting in, 240 
Ulcer, round, prescriptions, 275 
Urea in urine, 27 
Urine, 

acidity of, 26 

chlorides in, 28 

phosphates in, 28 

quantity of, 20 

study of, 26 

toxic substances in, 28 

urea in, 27 

Van Noorden's experiments 

in study of excreta, 25 
Vegetarian dietary of Dujar- 

din-Beaumetz, 55 
Vomiting, 

cannabis indica in, 157 

chloroform water. 157 

cocaine, 157 

cold drinks, 157 

counter-irritation, 158 

electricity, 158 

forced feeding, 158 

ice, 157 

lavage, 158 

menthol, 158 

morphine, 157 

Riviere's potion, 157 

tincture of iodine, 158 

Whey cure, 57 

Winter and Hayem's method 
of study of gastric juice, 7 

Winter's method of examina- 
tion of gastric juice, 18 

ZlEMSSEN'S, vox, method of 
exploring colon, 6 



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